Pain Assessment, Diagnosis, and Evaluation
Assessment as a biopsychosocial process
Start with history: onset, location, quality, temporal pattern, aggravating and relieving factors, associated symptoms, prior treatments, function, sleep, mood, substance use, and patient goals. Use a numeric rating scale or visual analog scale for intensity, but function and interference matter more. Neuropathic screens such as DN4 or LANSS support but do not replace the examination. Screen for depression, anxiety, catastrophizing, and opioid risk with validated tools. Red flags include fever, weight loss, night pain, neurologic deficit, bowel or bladder change, cancer history, trauma, and injection drug use.
Examination includes inspection, palpation, range of motion, neurologic testing of strength, reflexes, and sensation, straight-leg raise, gait, and pain behavior. Imaging is indicated only when it changes management and aligns with history and examination.
Traps: a 2-point numeric rating drop may not be meaningful; 30% improvement is a common responder threshold. Do not label patients drug seeking when pain is undertreated; pseudoaddiction is not a diagnosis. Widespread tenderness alone does not confirm fibromyalgia. Pain scales are not ratio scales.
Worked example: one patient reports pain 8/10 but walks, works, and sleeps; another reports 5/10 but cannot dress. The second has greater functional impairment, so target function rather than the score alone. Rule of thumb: ask what the patient cannot do and document a functional goal.