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musheera
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Approach to assessment and diagnosis of chronic pain
« on: /November/ 30, 2005, 06:10:15 PM »

Approach to assessment and diagnosis of chronic pain

Stephen Brunton
The clinical assessment of a patient with chronic pain is a dynamic process with several specific goals (TABLE 1) that ultimately lead to the implementation and ongoing refinement of a comprehensive, yet targeted management plan. A critical first step, however, is to acknowledge to the patient that you believe the pain is real, and that although elimination of the chronic pain is likely not realistic, you will work with him/her to reduce the pain and improve his/her quality of life.

Clinicians should be cautioned not to rush through the assessment in an effort to bring immediate relief to the patient's suffering. Establishing a diagnosis, at least tentatively, is important so that a treatment plan can be implemented that will result in short- and long-term pain relief, while minimizing side effects. The "PQRST" mnemonic (Palliative or precipitating factors, Quality of pain, Region of radiation of pain, Subjective description of pain, Temporal nature of pain) may provide a useful guide to assessment. The history and physical examination are particularly important in establishing the diagnosis. In fact, physicians who focus on this and their patient's health behaviors are much more likely to diagnose pain. (1) Of course, there are several aspects to a comprehensive pain assessment (TABLE 2). (2) [Evidence level: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates an absence of directly applicable clinical studies of good quality. Available at: http://www.guideline.gov/ summary/summary.aspx?ss=15&doc=id=3720&nbr:2946&string=.]

* CHARACTERIZING THE PAIN

Pain may be categorized according to its duration and onset, ie, acute, chronic, or breakthrough. Acute pain may have a sudden or recent onset but is transient in nature. Chronic pain is defined as pain that persists beyond the time normally associated with healing for a specific illness or injury. Chronic pain can be either associated with an unrelenting abnormality or recurrent. Breakthrough or incident pain can occur with numerous pain syndromes and be severe enough to significantly compromise function and quality of life.

Pain also is categorized according to its etiology as nociceptive, neuropathic, or mixed-type (FIGURE 1). Nociceptive pain can be considered a physiologically appropriate response to the inflammation caused by activity in neural pathways in response to noxious stimuli that damage tissue. Consequently, nociceptive pain serves a protective function by alerting a person that tissue damage is imminent or has already occurred; it prompts a response to avoid further noxious stimuli. Nociceptive pain usually is finite, localized, and resolves with normal healing or removal of the tissue-damaging stimuli. (3) Visceral and somatic pain are subsets of nociceptive pain. Examples of nociceptive pain commonly seen in clinical practice include arthropathies, mechanical low back pain, sickle cell crisis, sports injuries, ischemic disorders, postoperative pain, and skin and mucosal disorders. Most nociceptive pain syndromes involve acute pain, although the arthropathies, and sometimes, low back pain, are notable exceptions.

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musheera
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Re: Approach to assessment and diagnosis of chronic pain
« Reply #1 on: /November/ 30, 2005, 06:12:07 PM »

In contrast, neuropathic pain (NP) is initiated or caused by a primary lesion or dysfunction in the peripheral or central nervous system. (4) These abnormalities within the nervous system likely lead to a reorganization of sensory transmission pathways that continues after healing has taken place. Many types of NP are considered a chronic pain disorder. Unlike nociceptive pain, NP is pathophysiologic and serves no useful purpose.

Numerous mechanisms have been postulated as substrates for NP; in any given patient, multiple mechanisms may coexist, including excitotoxicity, abnormal expression of sodium channels, ectopic discharge, deafferentation, or central sensitization, (5-8) These underlying mechanisms are increasingly important considerations when selecting therapy, as will be discussed in the Dr McCarberg's article.

Neuropathic pain can be divided into 3 broad categories based upon presentation and distribution of symptoms. The first category is peripheral mononeuropathy (eg, carpal tunnel syndrome, trigeminal neuralgia, postherpetic neuralgia, and complex regional pain syndrome). The second is peripheral polyneuropathy (eg, diabetic and human immunodeficiency virus [HIV] neuropathy) and the third category is central neuropathy (eg, poststroke syndrome, spinal cord injury and HIV myelopathy). (3,9)

While some types of chronic pain may be classified clearly as nociceptive or of neuropathic origin, other chronic pain disorders are of the mixed type and involve both nociceptive and neuropathic elements. An example of a mixed-type pain syndrome is chronic, recurrent headache.

* HISTORY

A detailed history establishes a solid foundation to guide further diagnostic workup and to implement a comprehensive management plan. The initial and, perhaps, most critical step in taking the history is to let the patient tell his/her own story. Unless the patient is cognitively impaired, this is the best source of information regarding the pain. Listening to the patient helps to identify specific issues that warrant further investigation. It also serves to validate the patient's pain and forges a trusting relationship with the patient. The use of the Personal Pain Tracker has been shown to improve patient perception of the quality of the primary care physician-patient communication and contribute to greater overall satisfaction with medical visits. (10) The Personal Pain Tracker is a self-administered clinical diagnostic aid that assesses 9 aspects of pain in a questionnaire and pictorial format and includes 20 pain descriptors shown to be familiar to patients.

Because pain is a subjective experience and individual pain thresholds and analgesic responsiveness differ, a patient self-report is the most reliable indicator of the existence and intensity of pain. In addition to the patient's self-report, specific questions should be asked to assess the physical and psychosocial aspects of pain (TABLE 3). (11,12) The initial evaluation should include a thorough analgesic history, including current and previously used prescription medications, over-the-counter medications, complementary or alternative remedies, and alcohol use or abuse. The effectiveness and any side effects of current and previously used medications should be recorded. The patient's satisfaction with current pain treatment or health should be determined, and concerns should be identified. [Evidence level IIIB: Evidence from respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. Moderate evidence to support the use of a recommendation; clinicians "should do this most of the time." Available at: http://www.guideline.gov/summary/ summary.aspx?ss=15&doc_id=3365&nbr=2591& string=persistent%20AND%20pain.]

The differentiation of chronic nociceptive pain from chronic NP based upon symptoms may be challenging as there may be considerable overlap in the patient's descriptions. (13) Symptoms that are more suggestive of NP include numbness, tingling, continuous burning pain, electrical or other abnormal sensations (as can be seen with chronic dysesthesias, which are unpleasant abnormal sensations) or sharp, stabbing, shooting, knifelike pains, often following a sudden paroxysmal pattern. (14) Even among the NP syndromes, there is variability in the pain descriptors, which supports the belief that different mechanisms are involved. (15) For example, patients with postherpetic neuralgia often identify their pain as being more sharp, less cold, more sensitive, and itchier than pain identified by patients with diabetic neuropathy, peripheral nerve injury, or reflex sympathetic dystrophy. (16) Patients with lung cancer identify their pain as throbbing, aching, numb, tender, punishing, pulling, tugging, pricking, penetrating, miserable, and nagging. (13)

Neuropathic pain may manifest itself as negative symptoms (sensory loss) or positive symptoms such as paresthesias (abnormal sensations) or hyperalgesia (increased response to painful stimuli). Negative symptoms might result from impaired conduction of afferent sensory nerve activity that results in an area of sensory deficit, which is perceived as numbness. A negative symptom also can be caused by impaired conduction of efferent motor nerve activity, which can lead to muscle deficits, experienced by patients as weakness. Enhanced sensations or positive symptoms also may be observed ranging from paresthesias, such as tingling and prickling, to hyperesthesias (heightened but not painful sensations), to dysesthesias. This explains why a cold stimulus such as ice may reduce nociceptive pain due to inflammation but produce excruciating pain in NP. (7) A diagnosis of NP may be missed if the signs and symptoms of neural dysfunction are not recognized. Conversely, a patient with nerve damage and coincidental pain from another source may be misdiagnosed as having only NP. (17)

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musheera
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Re: Approach to assessment and diagnosis of chronic pain
« Reply #2 on: /November/ 30, 2005, 06:12:51 PM »

 PAIN ASSESSMENT TOOLS

Numerous tools have been developed and validated to assist in the assessment of pain (TABLE 4). (11,18-23) Those that are easiest to use have limited value, as they measure pain intensity only (unidimensional). Multidimensional tools assess several aspects of pain such as intensity, frequency, temporal nature, impact on quality of life, etc. Consequently, multidimensional tools are more difficult to complete, are time-consuming, and require expert interpretation. One notable exception is the short form of the Brief Pain Inventory (BPI). The BPI asks patients to identify the location of their pain on a diagram of the body, and it assesses the pain at its worst, least, and average intensity using a simple Likert scale to assess the impact of pain on activities of daily living. Multidimensional tools often assess the psychosocial factors that may be contributing to the pain. Since they provide more detailed information than unidimensional tools, multidimensional tools are particularly valuable in the evaluation of patients with complex pain syndromes. Selection of an appropriate pain assessment tool should take into consideration the person's cognitive development, language, culture, and preferences. It is prudent to use the same pain assessment tool for the person on subsequent assessments to facilitate reliable evaluations of changes in the pain. [Evidence level B: There is evidence of types II, III, or IV, and findings are generally consistent. II. Well-designed experimental studies. III. Well-designed, quasiexperimental studies, such as nonrandomized controlled, single-group prepost, cohort, time series, or matched-case controlled studies. IV. Well-designed nonexperimentat studies, such as comparative and correlational descriptive and case studies. Available at: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=3691&nbr=2 917&string=chronic%20AND%20pain%20AND%20diagnosis.]

The Numeric Rating Scale (NRS), Verbal Rating Scale (VRS), and Visual Analogue Scale (VAS) are widely used unidimensional scales that lend themselves to the primary care setting more readily than do the multidimensional tools. The NRS and VRS require the patient to rate the pain intensity on a scale from 0 to 10 (FIGURE 2), while the VAS uses a nongraduated 10-cm line. These 3 scales are simple to use, yield reproducible results, and are easily understood by most types of patients. The Faces Pain Rating Scale depicts images of facial expression ranging from a happy, smiley face to a very distressed, teary face (FIGURE 3). This type of scale is commonly used when communication may be difficult (eg, in young children and cognitively impaired adults).

[FIGURES 2-3 OMITTED]

The uni- and multidimensional pain assessment tools are reliable and valid measures of pain intensity and pain unpleasantness. Since they do not adequately assess the domains affected by NP, the Neuropathic Pain Scale (NPS) and the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) were developed. The NPS includes 2 items that assess the global dimensions of pain intensity and pain unpleasantness, as well as 8 items that assess specific qualities of NP. (16) An eleventh item assesses the temporal sequence of pain. The LANSS is a 2-part tool consisting of a patient-completed questionnaire and a brief clinical assessment of sensory dysfunction. (24) Its use provides immediate information in clinical settings. (25,26)

Most general pain assessment tools, including the Arthritis Impact Measurement Scale, do not assess pain during movement, especially movement that places stress on the hip or knee. They are, therefore, inadequate to assess pain due to osteoarthritis of the hip or knee. In this setting, the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) is the most widely used and is recommended by the World Health Organization. The WOMAC is a multidimensional tool that groups symptoms into 3 categories: pain, stiffness, and physical function. The WOMAC has been used successfully in patients with cognitive impairment. (22)

* PSYCHOSOCIAL ASSESSMENT

A critical part of the evaluation of a patient with chronic pain is the assessment of psychosocial risk factors. Ten largely independent psychosocial risk factors have been shown to serve as obstacles to the recovery from acute pain, thereby serving as risk factors for the development of chronic pain (TABLE 5). (12) A history of substance abuse or dependence is an important consideration in developing the management plan. Pain duration also is of particular importance as it is directly related to the likelihood that chronic pain and disability will develop. Patients who are unemployed for 6 months have a 50% chance of returning to their old job; after a year, there is only a 10% chance of a successful return to work. (12) This serves to reinforce the importance of correctly identifying the pain syndrome and implementing a comprehensive management plan.

Other issues of critical importance to primary care clinicians are the 5 psychosocial risk factors that are predictive of a negative outcome in the treatment of chronic pain (TABLE 6). (12) Negative beliefs predispose the patient to think that a return to work is not possible unless the pain is completely eliminated. When coupled with job dissatisfaction or an attitude of anger or hostility, resolution of chronic pain symptoms is particularly difficult. Multidisciplinary treatment and psychotherapeutic intervention may prove necessary.

Anxiety and depression are particularly important factors that may contribute to chronic pain. (27-29) Preliminary evidence suggests that these psychopathologies are preexisting, semidormant characteristics of the individual that are activated by a stressful event such as chronic pain. (30) Anxiety, for example, has been found to decrease the pain threshold and tolerance, (31) whereas depression is associated with less successful treatment outcomes. (32) Anxiety and depression have been associated with magnification of medical symptoms. (33)

Various assessment tools have been employed to assess the psychosocial contribution to chronic pain. Some of those most commonly used include the Beck Depression Inventory (BDI), the Spielberger State-Trait Anxiety Inventory (STAI), and the Minnesota Multiphasic Personality Inventory (MMPI). The BDI is a 21-item questionnaire that is easy to use and score. It reliably distinguishes between depressed and nondepressed patients with chronic pain. The STAI is a 40-item questionnaire that asks patients how they feel at present (state anxiety) and how they feel generally (trait anxiety). The MMPI is widely used by pain specialists. It takes 1 to 2 hours to complete, has a strong orientation to psychopathology, and is sometimes perceived by patients as implying that their pain is imaginary. (12,34)

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musheera
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Re: Approach to assessment and diagnosis of chronic pain
« Reply #3 on: /November/ 30, 2005, 06:14:55 PM »

PHYSICAL EXAMINATION

A thorough general physical and neurologic examination is essential for diagnosing chronic pain disorders. The examination should, of course, serve to verify the preliminary impression from the history and guide the selection of laboratory and imaging tests. Appearance, attitude, and behavior can provide important clues to the location and intensity of the pain. Speed of movement, gait, use of assistive devices, grimacing, and rubbing all convey important information. These can be investigated further by pain-provoking maneuvers, including range-of-motion determination. Adaptive behaviors employed by the patient to minimize the pain should be noted. (11,35) The physical examination should include careful examination of the site of reported pain, common sites for pain referral, and common sites of pain in older adults. It should also focus on the musculoskeletal system (eg, myofascial pain, fibromyalgia, inflammation, deformity, posture, leg length discrepancy), as well as the neurologic system (eg, search for weakness, hyperalgesia, hyperpathia, allodynia, numbness, paresthesia, other neurologic impairments). [Evidence level: IIIA. Evidence from respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. Good evidence to support the use of a recommendation; clinicians "should do this air the time." Available at: http://www.guideline.gov/summary/ summary.aspx?ss=15 &doc_id:3365&nbr=2591&string:persistent%20AND%20pain.]

In addition to the general physical examination, the system involving the pain complaint should be closely assessed. The neurologic and musculoskeletal systems also should be assessed in detail generally. The diagnosis of NP particularly relies on the demonstration of sensory abnormalities in the area innervated by the damaged nerve. Patients may have a paradoxical response to different stimulation tests in the same nerve distribution. To identify the sensory abnormalities present, a variety of instruments should be used, such as warm and cold objects for temperature sensation, a camel-hair brush or cotton swab to detect touch or allodynia, and a pin for detecting pain and hyperalgesia. (17) The functional examination of the musculoskeletal system is intended to determine if the pain is associated with specific musculoskeletal function or dysfunction. Examination of the spine serves to identify muscular strain, joint sprain, space-occupying lesions, and fracture. When joint pathology is suspected, range of motion, with assistance if needed, should be assessed. (11,35,36)

* LABORATORY AND DIAGNOSTIC TESTING

As there is no single diagnostic test for pain, laboratory and diagnostic testing serve to confirm or exclude underlying causes, such as rheumatoid arthritis, diabetes mellitus, spinal disorders, HIV, or herpesviruses. In addition, laboratory and diagnostic testing are useful to guide disease-specific treatment. Tests should not be ordered unless their results will affect decisions about treatment. [Evidence level: IIIA. Evidence from respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. Moderate evidence to support the use of a recommendation; clinicians "should do this most of the time." Available at: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id =3365&nbr=2591&string=persistent%20AND%20pain.]

In many NP syndromes, the results of clinically available laboratory tests are normal. For example, nerve conduction velocity (NCV) and electromyography (EMG) measure only the status of large nerve fibers, and cannot assess small-fiber function. Since many painful neuropathies affect only the small nerve fibers, the NCV and EMG tests will be normal. Diagnostic testing that could assist in diagnosis (eg, quantitative sensory testing) often requires specialized equipment and interpretive expertise not generally available in the primary care setting. Diagnostic imaging often is not useful initially in identifying the anatomic cause of the chronic pain since the abnormalities causing the pain may not be detected, while other abnormalities may be. Instead, imaging should be used generally to confirm or rule out the suspected cause of the chronic pain. For example, in patients 50 years of age and older with low back pain, simple radiography is useful to rule out underlying systemic diseases, (37) while magnetic resonance imaging is useful to identify patients suspected of having early-stage rheumatoid arthritis. (38)

* SUMMARY

A thorough assessment is essential to the effective short- and long-term management of chronic pain. Patient self-report is the most important source of information in pain assessment. Numerous assessment tools to characterize the pain as well as possible contributing factors, are available and can be used to complement the history and physical examination. Laboratory and diagnostic testing are primarily used to confirm or exclude underlying causes.

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musheera
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Re: Approach to assessment and diagnosis of chronic pain
« Reply #4 on: /November/ 30, 2005, 06:17:20 PM »

Goals of pain assessment

* Establish a diagnosis of pain

* Determine the type and severity of the
pain disorder

* Identify the pain mechanism(s)

* Assess the impact on functional status,
quality of life

* Identify contributing factors, including comorbid
conditions and psychosocial factors

* Establish treatment goals and an initial
management plan

* Refine the management plan as needed to
optimize patient outcomes

* Determine if consultation with specialist
or multidisciplinary team is needed

TABLE 2

Aspects of comprehensive pain assessment

* Physical examination, relevant laboratory
and diagnostic tests

* Effect of and understanding of current illness

* Meaning of pain and distress caused by the pain

* Coping responses to stress and pain

* Effects on activities of daily living (especially in
frail older persons and noncognizant persons)

* Psychosocial and spiritual effects

* Psychologic/social variables (anxiety, depression)

* Situational factors--culture, language, ethnic
factors, economic effects of pain and treatment

* Person's preferences and expectations/beliefs/myths
about pain management methods and person's
preferences and response to receiving information
related to his/her condition and pain

TABLE 3

Issues to be covered in the history

* What are location and character of pain?

* Is the pain continuous or intermittent?

* How and when did the pain start?

* Are there any relevant comorbidities?

* What are exacerbating and relieving factors?

* What is the effect of certain positions and activities
on pain?

* What is the effect of stress, alcohol, and other
substances on the pain?

* Is there an associated sleep or mood disturbance?

* What is the effect of pain and its treatment on
functioning at work or school?

* What is the effect of pain and its treatment on quality
of Life, including cognitive, social, sexual function?

* Does the patient have an ulterior motive (eg,
lawsuit, disability, desire for attention)?

* Does the patient blame anyone for the pain?

* Has the patient previously sought medical assistance
for the pain?

* What treatments have been or are being used?

TABLE 4

Pain assessment tools

Tools                  Strengths                 Weaknesses

UNIDIMENSIONAL

Numeric Rating Scale   Simple; reproducible;     Measures pain inten-
(NRS)                  can measure small         sity only; difficult
                       change in pain inten-     to use in cognitively
                       sity; can be verbally     impaired persons
                       administered; easily
                       understood by most,
                       including older persons
                       and different cultures;
                       used in prehospital
                       setting
Verbal Rating Scale    Simple; reproducible;     Measures pain inten-
(VRS)                  can measure small         sity only; not as
                       change in pain inten-     sensitive as the NRS
                       sity; can be verbally     or Visual Analog Scale
                       administered, easily
                       understood by most, in-
                       cluding older persons;
                       high completion rate in
                       cognitively impaired;
                       used in prehospital
                       setting
Visual Analogue        Simple; reproducible;     Measures pain inten-
Scale (VAS)            can measure small         sity only; requires
                       change in pain inten-     careful instruction;
                       sity; can be used in      difficult to use in
                       different cultures        cognitively impaired;
                                                 visual impairment may
                                                 affect accuracy
Faces Pain             Simple; useful in young   Measures pain inten-
Rating Scale           children, developmen-     sity only; requires
                       tally disabled, cog-      careful instruction;
                       nitively impaired, and    visual impairment may
                       in different cultures     affect accuracy
Knee Pain Scale        Useful in patients with   A bit cumbersome to
                       knee osteoarthritis;      use
                       assesses frequency and
                       intensity of knee pain

MULTIDIMENSIONAL

McGill Pain            Combines words and        Time-consuming; re-
Questionnaire          pictures to provide       quires careful ins-
(MPQ)                  a general analysis of     truction; not easily
                       overall pain expe-        used in cognitively
                       rience; shortened         impaired or in diffe-
                       version generally more    rent cultures
                       appropriate
Brief Pain             Combines ratings of       Time-consuming;
Inventory (BPI)        intensity and location;   requires careful
                       useful in different       instruction; not
                       cultures; BPI short       easily used in
                       form generally more       cognitively impaired;
                       appropriate in clinical   used mostly in
                       practice                  clinical research
Minnesota              Uses several scales to    Requires careful
Multiphasic            predict treatment         instruction; time-
Personality            outcome                   consuming; developed
Inventory (BPI)                                  for a general--not
                                                 pain--population;
                                                 ability to predict
                                                 treatment outcome is
                                                 variable
Checklist of Non-      Clinician evaluation      Low reliability and
verbal Indicators      of 6 pain-related         validity
                       behaviors at rest and
                       during movement;
                       developed for use in
                       cognitively impaired
Western Ontario and    Assesses disease          Time-consuming; user
McMaster University    progression in            fee required
Osteoarthritis Index   osteoarthritis; 5-point
(WOMAC)                Likert and VAS ver-
                       sions; recommended by
                       the World Health Orga-
                       nization; useful in
                       cognitively impaired,
                       different cultures
Arthritis Impact       Useful in all types of    Time-consuming; does
Measurement Scale      arthritic pain            not focus on specific
(AIMS)                                           features/locations of
                                                 pain
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musheera
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Re: Approach to assessment and diagnosis of chronic pain
« Reply #5 on: /November/ 30, 2005, 06:21:30 PM »

Psychosocial risk factors
for the development
of chronic pain and disability

* Pain duration
* History of major psychopathology
* History of substance abuse or dependence
* Job dissatisfaction
* History of prolonged recovery from previous
  experiences of pain
* Pattern of reduced activity, coupled with excessive
  pain behaviors, supported by family and other
  social contacts who are either too solicitous or
  inconsistent or too harsh and punitive
* History of psychologic or physical trauma
* History of emotional, physical, or sexual abuse
* Negative or anxiety-provoking beliefs
  about the meaning of pain
* Explanatory model of pain

TABLE 6

Psychosocial risk factors
for a negative outcome of
chronic pain treatment

* Job dissatisfaction
* Reduced activity
* Negative beliefs
* Sustained attitude of hostility, anger, and alienation
* Reliance on maladaptive coping strategies
REFERENCES

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(2.) Registered Nurses Association of Ontario. National Guideline Clearinghouse web site. Assessment and management of pain. Available at: http://www.guideline.gov/summary/ summary.aspx?ss=15&doc_id=3720&nbr=2946&string=. Accessed May 13, 2004.

(3.) Galer BS, Dworkin RH. A Clinical Guide to Neuropathic Pain. Minneapolis, MN: McGraw-Hill; 2000.

(4.) Fakata KL, Lipman AG. Pharmacotherapy for pain in rheumatologic conditions: the neuropathic component. Curr Pain Headache Rep. 2003;7:197-205.

(5.) Baron R. Peripheral neuropathic pain: from mechanisms to symptoms. Clin J Pain. 2000;16(2 suppl):S12-S20.

(6.) Galer BS. Neuropathic pain of peripheral origin: advances in pharmacologic treatment. Neurology. 1995;45(12 suppl 9):S17-S25.

(7.) Taylor BK. Pathophysiologic mechanisms of neuropathic pain. Curr Pain Headache Rep. 2001;5:151-161.

(8.) Brookoff D. Chronic pain: 1. A new disease? Hosp Pract (Off Ed). 2000;35:45-52,59.

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Stephen Brunton, MD

Director of Faculty Development, Cabarrus/Northeast Medical Center, Family Medicine Residency, Charlotte, NC

COPYRIGHT 2004 Dowden Health Media, Inc.
COPYRIGHT 2004 Gale Group
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