History and exam
Key diagnostic factors
common
presence of risk factors
Female sex; patients aged over 45 years; family history of chronic pain (particularly migraine or fibromyalgia); pregnancy; history of trauma or chronic pain; history of acute back pain with neurological symptoms; pain-related disability; high-risk occupations.
duration of pain more than 3 months
Chronic pain syndromes are associated with pain being present more than 3 months.
physical comorbidity
History and complete review of systems is required to identify medical conditions that may be related to chronic pain complaints, such as endocrine dysfunction (including hypothyroidism), arthritis, chronic fractures, malignancy, and neuropathic pain conditions (such as diabetes mellitus and shingles).
A history of head injury is key in patients with post-traumatic headache (persistent headache attributed to traumatic injury to the head or neck).[2]
psychological comorbidity
Nearly half of all patients with a pain disorder have associated psychological or psychiatric comorbidity; these include depression, anxiety, and personality disorder. Comorbid psychological symptoms or psychiatric disorders can negatively affect the patient’s ability to participate in pain rehabilitation and should be treated separately.[28] These factors may be addressed through pain management psychology.
previous history of acute pain episodes
There may be a history of acute pain episodes, which predispose to the development of chronic pain syndromes; these include back pain with restricted lumbar flexion, pain of insidious onset, and back pain radiating to the lower extremity.
pain causing difficulty in performing routine activities of daily living
Patients who report significant pain-related disability for activities of daily living or work are more likely to have persistent chronic pain.[23]
precipitating factors for myofascial pain
Pain precipitated by physical activity is seen in myofascial pain (repetitive overuse). Precipitating factors may be addressed through activity modification by occupational therapy.
precipitating factors for musculoskeletal pain
Pain precipitated by physical activity is seen in musculoskeletal (mechanical) pain. Precipitating factors may be addressed through activity modification by occupational therapy.
herpes zoster infection
In postherpetic neuralgia, pain persists for more than 1 month after the onset of herpes zoster (occurs in about 30% of patients following acute zoster, and lasts 1 year in about 10%).[19]
history of trauma or limb immobilisation
Complex regional pain syndrome may develop following an identified injury or period of limb immobilisation (e.g., casting) and may be divided into type 1 (occurring in the absence of a nerve injury) and type 2 (occurring after injury to a specific large nerve). Chronic headache may also follow a history of trauma.
drug use
muscle spasm
Associated symptoms such as muscle spasm are in keeping with myofascial pain.
associated somatic symptoms
Seen in all chronic pain syndromes but particularly in fibromyalgia, associated somatic symptoms are common and include irritable bowel syndrome, diffuse sensory changes, genitourinary disturbances, and disturbances in sleep and mood.
muscle tenderness to palpation
Muscle tenderness may be due to myofascial pain.
trigger-point tenderness
Localised, discrete tenderness over painful muscle spasm is seen in myofascial pain.
taut bands
Taut bands are a key sign in myofascial pain syndromes and consist of palpable contracted cord-like groups of muscle fibres.
twitch response
In myofascial syndromes there is point tenderness over taut bands and local twitch response, which is the involuntary contraction of taut band after it is physically plucked or a needle is inserted into it.
joint swelling and tenderness
Typical of musculoskeletal pain due to arthritic conditions.
tender points
Patients with fibromyalgia have widespread tenderness to palpation over pre-specified points that may not be within areas of pain complaints. Local injections into these tender points are not beneficial. Completion of a pain diagram may be helpful.[38]
Other diagnostic factors
common
precipitating factors for chronic headache
Pain precipitants are important in the history of chronic headache: for example, chronic headache episodes lasting more than 2 hours and precipitated by stress are in keeping with tension-type headaches, and those precipitated by triggers may be migraine headaches.
Precipitating factors may be addressed through activity modification by occupational therapy.
duration of headache pain
Pain duration is an important part of the history of chronic headache: for example, headache episodes lasting less than 2 hours are in keeping with chronic cluster headaches, and episodes lasting more than 2 hours are in keeping with either migraine or tension-type headaches.
radiating pain
Radiating pain may signify myofascial active trigger points or radicular pain.
morning stiffness in joints
Patients with rheumatoid arthritis or osteoarthritis may report morning stiffness in joints.
pain with prolonged walking, relieved with stooping or sitting
May be associated with lumbar spinal stenosis.
joint pain
May be due to an arthritic condition.
burning quality of pain
May indicate neuropathic pain.
allodynia
Typical of neuropathic pain. Allodynia is the perception of non-noxious stimuli as painful.
hyperalgesia
Typical of neuropathic pain. In hyperalgesia, noxious stimuli produce exaggerated or prolonged pain.
chronic headache associated with nausea, vomiting, and sensitivity to light and noise
Associated features are important in the history of chronic headache: for example, chronic headache episodes associated with nausea, vomiting, and sensitivity to light or noise are likely to be migraine headaches.
A sudden, acute, severe headache with these associations may initiate neurological referral and investigations to exclude subarachnoid haemorrhage.
intermittent pattern of chronic headache pain
In chronic headache syndromes, an intermittent headache pattern is seen in post-trauma headache and cluster-type headaches.
bilateral chronic headache pain
Typical of medication overuse, tension-type, post-traumatic, and chronic migraine headaches.
unilateral chronic headache pain
Typical of cluster-type headaches; involves the eye.
limited range of motion (ROM)
Active ROM often restricted in both myofascial and mechanical pain; passive ROM restrictions suggest mechanical pain.
painful or limited straight leg raising
May be seen in neuropathic radicular pain.
uncommon
symmetrical body pain distribution
Seen in fibromyalgia and polymyalgia rheumatica.
worsening headache symptoms despite treatment
Warning symptom that requires consultant referral and further work-up.
headache with posterior head or neck pain
Warning symptom (e.g., of possible head or neck trauma or vertebral artery dissection) that requires consultant referral and further work-up.
excessive guarding of the painful extremity
May be seen in complex regional pain syndrome and in other neuropathic conditions.
diminution or loss of reflexes
May be seen in neuropathic pain.
tenderness over temporal artery distribution
When associated with headache, with visual disturbance and in patients with polymyalgia rheumatica (PMR), investigations may be initiated to exclude giant cell (temporal) arteritis (GCA), which may include biopsy diagnosis and urgent treatment.
Around 15% to 20% of patients with PMR have GCA; 40% to 60% of GCA patients have PMR.[43]
Risk factors
strong
age over 45 years
Prevalence increases with increasing age (especially for pain due to musculoskeletal causes), so the number of people living with chronic pain worldwide will increase as life expectancy increases.[4]
Common pain syndromes in older people include arthritis, lumbar spinal stenosis, and osteoporosis with fractures.
female sex
pregnancy
Increased risk for a variety of musculoskeletal and neuropathic pain complaints.[3]
history of trauma or chronic pain
Personal history of trauma or chronic pain; work absence due to pain complaints will likely require more aggressive management.
family history of chronic pain syndromes
Associated with increased likelihood of developing a chronic pain syndrome, requiring more aggressive management. Genetic factors increase predisposition to developing migraine and fibromyalgia.
acute back pain with neurological signs
Among patients with acute back pain, those with neurological signs or radiating pain are more likely to develop chronic pain.[23]
high-risk occupation
Occupations such as some healthcare workers (e.g., healthcare assistants, nurses, dentists, and chiropractors), heavy manual workers, car mechanics, housekeepers/caretakers, hairstylists, and other occupations involving prolonged standing are associated with an increased risk of chronic back pain.[24][25][26]
Myofascial pain is most common in people who carry out sustained low-level movements, such as office workers, musicians, and dentists.[8]
Chronic pain has also been shown to be prevalent in soldiers.[27]
Routine occupations, unemployment, and previous job change due to pain are also risk factors for pain chronicity.[5][6]
comorbid personality disorder/psychological distress
Pre-morbid psychological distress, depression, anxiety, catastrophising, and somatisation. Screening for mood disorders and other distress should be a routine part of the chronic pain evaluation, with recommendations for treatment incorporated into the pain management regimen.[23]
Co-existing psychopathology is important to identify and treat, as psychological distress can negatively affect participation in chronic pain therapy, functional rehabilitation, and treatment compliance.[28]
Comorbid personality disorders can affect care of patients with chronic pain. Even among primary care populations, the prevalence of personality disorders among chronic pain patients can be substantial in some patient samples.[29][30][31]
pain-related disability
Patients who report significant pain-related disability for activities of daily living or work are more likely to have persistent chronic pain.[23]
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