Table 4. Noninvasive, Nonpharmacologic Treatments for Specific Pain Conditions 30
Pain Condition
Treatment
Chronic low back pain
Exercise, psychological therapies (primarily cognitive behavioral therapy), spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, multidisciplinary rehabilitation, tai chi
Chronic neck pain Knee osteoarthritis Hip osteoarthritis
Exercise, low-level laser, Alexander Technique, acupuncture
Exercise, ultrasound
Exercise, manual therapies
Fibromyalgia
Exercise, cognitive behavioral therapy, myofascial release massage, tai chi, qigong, acupuncture, multidisciplinary rehabilitation
Chronic tension headache Spinal manipulation
Pain should be assessed by its severity (to include pain intensity, pain-related distress, and interference with daily activities), its temporal characteristics (to include onset, duration, whether it is continuous, has recurrent episodes with painless intervals, or is continuous with times of pain exacerbation). Psychological and social factors can contribute to the pain experience, which is why these issues should be included in the patient interview and documented in the record. Recording these factors will assist with documenting what special pain management needs a patient has as well as what level of disability. 23 Good questions to ask the patient include what relieves or increases the pain, how it affects their daily lives and functioning, and what goals they have for pain relief and improved function. A number of evidence-based, pain assessment tools are available for clinical practice: • The Visual Analogue Scale (VAS) and Numerical Rating Scale (NRS) are quick tools to measure pain severity that are sensitive, validated, and widely-used. 102 • The Brief Pain Inventory (BPI) has good sensitivity, reliability, and validity for pain severity and interference-with-function items, including assessments of mood and sleep. 103,104 • The Pain, Enjoyment of Life, and General Activity Scale (PEG) was created to assist management of chronic pain in primary care settings. 105 It is based on the BPI and has rating scales to measure past-week pain, pain interference, functional components, and quality of life. • The McGill Pain Questionnaire (MPQ) assesses pain descriptors (sensory, evaluative, and affective). 102 With good validity and reliability, the MPQ is useful for helping patients describe their subjective pain experience but requires a good vocabulary when self-administered. The MPG is also available as a short form. • The Multidimensional Pain Inventory has been validated for multiple chronic pain conditions for categorizing how well patients cope with chronic pain as adaptive, dysfunctional, or interpersonally distressed. 106,107 Numeric pain scales, such as the VAS or NRS, have limitations in that they provide only a snapshot of the pain on a given day and do not necessarily reflect the impact of pain on the patient’s life. One should also consider other clinical signs and symptoms and to make treatment decisions to
further therapeutic goals meaningful to the patient rather than basing treatments solely on a pain scale number. HCPs should also screen and monitor patients for factors associated with poor outcomes and substance abuse, such as sleep disturbance, mood disorder, and stress. HCPs are encouraged to consider use of a scale such as the Defense and Veterans Pain Rating Scale (DVPRS) (Figure 3). 1,108 The DVPRS is a graphic tool with a numeric rating scale in which each pain level has descriptive word anchors, facial depictions of pain, and color coding that coincides with pain severity categories. The DVPRS also includes supplemental questions for general activity, sleep, mood, and level of stress. This or other numeric pain scales may be particularly useful for assessing pain in patients who have language deficits or other issues with communicating their experience of pain. Figure 3. The Defense and Veterans Pain Rating Scale and Supplemental Questions 108
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