Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.
Note from the National Guideline Clearinghouse (NGC): For the Work Loss Data Institute's "Disclaimer: limitations of scope" statement, refer to the "Qualifying Statements" field in this summary or see the original guideline document.
Introduction
Pain has been classified in multiple ways. One common methodology is to temporally classify the condition according to duration, with the most common categories given as acute and chronic. Acute pain is a sign of real or impending tissue damage and usually disappears with healing. It is the normal predicted physiologic response and is usually of short duration. Chronic pain, a common and expensive problem in occupational and disability medicine, has been defined by multiple different time durations (generally from 6 weeks to 3 months after the onset of symptoms). It has also been defined as pain that persists for at least 30 days beyond the usual course of an illness. Chronic pain is a condition that ultimately adversely affects the patient's well being, level of function and quality of life. This chapter of Official Disability Guidelines (ODG) Treatment focuses on chronic pain.
Pain has also been classified according to presumed neurophysiologic mechanisms. There is no real consistency to this type of classification, but texts on pain suggest that pain is either of somatic/nociceptive origin, or a non-nociceptive origin; the latter commonly classified as neuropathic and/or idiopathic/psychogenic. (Definition: somatic pain is a pain arising in the body tissues typically associated with injury or trauma, and nociceptive pain is a normal and expected pain response to injury.) Nociceptive pain is not necessarily synonymous with acute pain. Examples of chronic pain conditions that have been classified as nociceptive include arthritis and other degenerative conditions such as rotator cuff disease.
Pain has also been described as an experience rather than a sensation. Chronic pain may occur without obvious tissue damage, and psychological components have a substantial impact on its development and chronicity. Pain societies have recognized that psychological input to pain may include components of cognitive, behavioral, emotional, and certain predisposing factors (such as childhood trauma or abuse), as well as a potential role of traumatic stress. In addition, in workers' compensation cases and other cases involving personal injury, the "sick role" is further reinforced by the promise that compensation (indemnification) may play in the process. Additionally, there is an increasing emphasis on the role psychiatric co-morbidities such as anxiety disorder, bipolar disease and addictive disease may play in the pathogenesis of the condition.
Initial Evaluation for Chronic Pain
History
- Determine the chief complaint.
- Determine if there was a specific incident that caused or triggered the onset of pain or if pain was insidious in onset.
- Determine the severity and specific anatomic location of the pain (including radiation patterns).
- Determine if the pain has remained localized, or if it become more multifocal/generalized.
- Determine the character of pain including the following:
- Quality of pain (by descriptions such as aching, dull, sharp, allodynia, burning, electric, dysesthesia, paresthesias, and or neuralgia)
- Continuous or intermittent
- Associated neurological factors (weakness, numbness, balance problems)
- Factors that exacerbate or relieve
- Effect of activity, body position
- Effect of stress
- Determine previous tests and results.
- Determine the effect of previous treatment including medications.
- Assess the ability of the patient to perform functions such as walking, lifting, sitting, and standing including job-related limitations.
- Assess for evidence of substance abuse in the patient in the past or currently (including alcohol, smoking, or illicit drugs). A family history should also be ascertained.
- Examine for evidence of concordant depression, anxiety, other mood disturbance, sleep disturbance, or eating disturbance.
- Assess the effect that pain has had on quality of life in regards to social and family interactions and sexual function.
- Assess for involvement of litigation or evidence of secondary gain.
- Assess the patient's goals of treatment.
Physical Examination
- Assess vital signs, weight, and body mass index. Assess pain using an instrument such as the visual analog scale (VAS), and functionality.
- Observe appearance, attitude and behavior (such as response on examination maneuvers), and gait.
- Observe for musculoskeletal defects: deformity, atrophy, masses or lesions, signs of trauma, alignment of spine, range of motion. Determine muscle strength, and evaluate for evidence of myofascial dysfunction.
- Assess neurologic status: mental status sensory examination (including hyperalgesia, hyperpathia, paresthesias, dysesthesias, allodynia, hypesthesia, hyperesthesia), muscle stretch reflexes.
- Assess pain-exacerbating maneuvers.
- Assess for Waddell's signs and inconsistencies in the above examination.
Begin an Assessment of the Presumed Chronic Pain Mechanism Based on the History and Physical
The Institute for Clinical Systems Improvement (ICSI) has differentiated distinct biological mechanisms that contribute to chronic pain. Each patient may have multiple and/or overlapping contributors. The criteria and suggested treatment of specific conditions listed are given in the Procedure Summary of the original guideline document.
Neuropathic Pain: Defined as "pain initiated or caused by a primary lesion or dysfunction of the nervous system." Neuropathic pain can be classified according to several methodologies. The first includes a classification into categories of peripheral, central, or a controversial category that includes "dysfunction of the nervous system." An alternative mechanism is to classify neuropathies associated with pain into the following: 1) mononeuropathies, either traumatic or from other causes; 2) polyneuropathies, with etiologies including metabolic, nutritional, drugs, toxins, hereditary, malignant, infective, or an "other" category. See the Procedure Summary in the original guideline document for recommendations concerning the use of various treatments and, in particular, medications such as antidepressants and anticonvulsants (e.g., gabapentin [Neurontin®]) for neuropathic pain.
Muscle Pain: Includes fibromyalgia and myofascial pain.
Inflammatory Pain: This type of pain mechanism is commonly associated with acute pain (postoperative pain and acute tissue injury). An example of chronic inflammatory pain includes arthritis.
Mechanical Pain: Examples of chronic conditions include etiologies that create pressure or stretching, resulting in pain including fracture, dislocation. Another chronic pain example would include compression of tissue by bony structures.
Psychological: In addition to the ICSI mechanisms, it is suggested in guidelines (such as the Chronic Pain Disorder Medical Treatment Guidelines, 2003) to also evaluate for psychological contributors. Specific examples of psychological contributors/comorbidities that are either associated with or contribute to chronic pain include depression, anxiety, personality disorders somatization, and post-traumatic stress. The possibility of the contribution of underlying substance abuse problems must also be assessed. Specific guidelines for both suggested and required psychological testing for specific treatment interventions are included in the Procedure Summaries of the original guideline document. Descriptions of specific standardized psychological tests are provided in "Psychological Tests Commonly Used in the Assessment of Chronic Pain Patients."
Secondary Gain Issues: Issues such as indemnity and current litigation may have impact on resolution of pain. Some authors also suggest even more important social contributors including the primary loss of physical health and functioning, as well as secondary losses such as loss of financial stability and relationships (both on a personal and work-related level).
Determine the Need for Specific Diagnostic Studies
Specific recommendations for diagnostic tests are given in the Procedure Summaries of the original guideline document for both the Pain Chapter and specific body-part chapters.
General Treatment Management
Specific recommendations for each condition are given in the Procedure Summaries of the original guideline document for both the Pain Chapter and specific body-part chapters. General management suggestions as suggested by ICSI also include the following:
- Develop a written plan of care that addresses the patient's personal goals, sleep, physical activity, stress management, and recommendations to improve pain control.
- Provide adequate information to the patient, including opportunities for education on their condition.
- Include the patient in the treatment plan.
- Acknowledge that the treatment team recognizes that their pain is considered as "real."
- Provide all patients with an exercise and fitness program.
- Consider the use of a cognitive behavioral program when indicated.
- Schedule routine appointments to avoid the incidence of visits secondary to increased pain.
- Stress self-management by the patient.
- Enlist family and friends to both support the patient and reinforce gains.
- Assist in return to work.
- Assist in appropriate attainment of entitlements.
At a certain point in the course of care, there are two general treatment options for claimants with chronic pain. One is medication, and the second is cognitive therapy/pain management programs. See the Procedure Summary in the original guideline document for more details and links to the medical evidence.
Medication Issues: (See also Medications in the Procedure Summary of the original guideline document for links to specific choices)
Non-neuropathic pain is generally treated with analgesics and anti-inflammatories. First-line treatment for neuropathic pain requires treatment with medications that influence the various transmitters involved in the underlying pain pathology, with opioids reserved for refractory pain. When considering opioids for either type of pain, discussion should include duration of treatment and when to discontinue their use (as occasionally suggested as "detoxification" by many reviewers). This area of opioid treatment remains extremely controversial, and research remains ongoing. It is generally felt that "detoxification" should not be proposed without offering another treatment solution, although alternative options also remain controversial.
Anticonvulsants are also currently suggested medications for neuropathically related chronic pain. When dealing with neuropathic pain, and in particular, neuropathic pain of possible spinal origin, treatment issues are confounded due to the presence of underlying non-work-related conditions that also can present with neuropathic pain such as impaired glucose tolerance/type 2 diabetes (i.e. diabetic peripheral neuropathy) and/or aging (possible neurogenic claudication secondary to spinal stenosis). The question often arises as to the actual indication of the use of anti-convulsant medication in these instances, and their compensability in regards to the work-related injury. These questions include how the medications should be prescribed and how outcomes should be recorded. Antidepressants have also been indicated for both neuropathic and non-neuropathic pain. Not only do compensability issues arise for this class of medications in regards to the underlying issues of etiologies of neuropathy, but also in regards to their use for pre-existing conditions of depression and anxiety. Needless to say, the issues involved with medication for chronic pain are controversial, and current literature addressing the above issues is included in the Procedure Summary in the original guideline document.
Note: In workers' compensation cases, providers may need to shift focus from a "cure and relieve" strategy to a "functional restoration" paradigm. Too much attention may be focused on the "pain" and not enough on functional restoration and gain that encourages "coping" strategies and the desirable outcome of "working" with pain. Also consider the possibility of patients developing "Wounded Worker Syndrome," a chronic pain condition characterized by failure of an injured worker to respond to conventional healthcare measures, and prolonged disability with continued absence from the workplace. The main contributor of this condition may be the healthcare system itself, which reinforces the "sickness" role of the injured worker and provides many misguided interventions due to a lack of adequate assessment of underlying psychosocial factors.
ODG Return-To-Work Pathways for Selected Generalized Pain Syndromes
(See body-part chapters for disability duration information for pain that is the result of conditions in specific body parts, such as low back, neck or extremity pain)
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ODG Return-To-Work Pathways
Myalgia and Myositis, Unspecified (Muscle Pain or Inflammation) (see the original guideline document for International Classification of Diseases, Ninth Revision [ICD-9] codes for this and other diagnoses)
Moderate pain: 0 days
Debilitating pain, with hospitalization, modified work: 14 days
Debilitating pain, with hospitalization, regular work: 42 days
Myofascial pain syndrome, trigger point injection: 1 to 7 days
Myofascial pain syndrome, acupuncture: 7 to 21 days
Myofascial pain syndrome, physical therapy: 14 to 21 days
Fibromyalgia: Controversial and self-perpetuating diagnosis - see related conditions and return to regular activities as soon as possible
Reflex Sympathetic Dystrophy (including complex regional pain syndrome [CRPS]-I)
Note: this is a controversial diagnosis
Sympathetic nerve block: 3 to 7 days
Complex regional pain syndrome (CRPS-I), early stage: 28 to 84 days
Complex regional pain syndrome (CRPS-I), late stage: 210 days to indefinite
Late stage reflex sympathetic dystrophy (RSD) (CRPS-I): 365 days to indefinite
Causalgia of Upper Limb (including CRPS-II)
Note: this is a controversial diagnosis
Medical treatment: 0 days
Sympathetic nerve block: 2 days
Complex regional pain syndrome (CRPS-II): 28 to 84 days
Causalgia of Lower Limb (including CRPS-II)
Note: this is a controversial diagnosis
Medical treatment: 0 days
Sympathetic nerve block: 2 days
Complex regional pain syndrome (CRPS-II): 28 to 84 days
Mononeuritis of Unspecified Site (including CRPS-II)
Note: this is a controversial diagnosis
Sympathetic nerve block: 3 to 7 days
Complex regional pain syndrome (CRPS-II), early stage: 28 to 84 days
Complex regional pain syndrome (CRPS-II), late stage: 210 days to indefinite
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