## KEY POINTS

KEY POINTS

1. Pain has an astounding impact on individuals, their families, and society as a whole. Pain affects over 100 million Americans, costing society over 0.5 trillion dollars per year.

2. Proper assessment of chronic pain starts with a detailed history and physical examination that supports the development of a differential diagnosis. Laboratory tests, electrodiagnostic tests, and radiologic imaging are meant to support or refute that diagnosis. These tests should not be used for broad screening.

3. Pain is a subjective experience that impacts multiple dimensions of physical, psychological, and social functioning. Capturing these domains through patient-reported outcome measurement can aid in clinical assessment, treatment decision making, and longitudinal monitoring.

## THE PROBLEM OF PAIN

While pain is an expensive, intrusive, and prevalent condition, it remains systemically challenging to classify and treat. Pain impacts more than 100 million Americans with significant socioeconomic consequences. According to the Institute of Medicine’s (IOM) 2011 report, Relieving Pain in America, the resulting financial toll of this epidemic is higher than that for heart disease, cancer, and diabetes combined, with an astounding $560-$635 billion per year in costs. Given the treatment challenges of this diverse group of medical conditions, detailed assessment of patients and their pain is a critical to successful treatment. Deconstructing the subjective and objective components of each patient’s personal pain experience allow for meaningful synthesis of that patient’s current condition and opportunities for optimization. This chapter provides a framework for that evaluation with key components this important step.

## DEFINING CHRONIC PAIN

Time is a key domain for understanding, diagnosing, and treating painful conditions. Pain is generally classified as acute or chronic pain. Acute pain is a fairly well defined process with a normal trajectory and pathway for healing and recovery. However, when acute pain persists and diverges from that pathway, it is classified as chronic pain. This progression is poorly understood, but according to the IOM report, chronic pain is fundamentally different from acute pain. This difference lies in that it is not the symptomatic response to injury, but is a disease in itself, one that fundamentally alters the entire nervous system with significant psychological and social consequences. Although chronic pain is primarily a disease of the nervous system, it also involves multiple systems, including the musculoskeletal, endocrine, immune, and inflammatory systems. Chronic pain can persist for years and progressively worsen functional status.

## WHY DIAGNOSIS IS IMPORTANT

Obtaining an accurate diagnosis is the first and most important step in optimizing treatment. It requires an analysis of the multiple systems involved in triggering and perpetuating the pain response in order to develop timely and systematic therapeutic treatments. The trajectory of treatment depends on the patient’s specific diagnosis and typically varies from one patient to another. Individualized care requires sophisticated coordination of other specialty physicians, psychologists, physical and occupational therapists, and other ...

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