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Chapter 8. Management of Patients with Chronic Pain

David M. Cline

Chronic pain is defined as a painful condition that lasts longer than 3 months. It also can be defined as pain that persists beyond the reasonable time for an injury to heal or a month beyond the usual course of an acute disease. Complete eradication of pain is not a reasonable endpoint in most cases. Rather, the goal of therapy is pain reduction and a return to functional status.

Signs and symptoms of chronic pain syndromes are summarized in Table 8-1. Most of these syndromes will be familiar to emergency physicians.

Table 8-1 Signs and Symptoms of Selected Chronic Pain Syndromes
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Table 8-1 Signs and Symptoms of Selected Chronic Pain Syndromes
DisorderPain symptomsSigns
Myofascial headacheConstant dull pain, occasionally shooting painTrigger points on scalp, muscle tenderness, and tension
Transformed migraineInitially migraine-like, becomes constant, dull, nausea, vomitingMuscle tenderness and tension, normal neurologic examination
FibromyalgiaDiffuse muscular pain, stiffness, fatigue, sleep disturbanceDiffuse muscle tenderness, > 11 trigger points
Myofascial back pain syndromeConstant dull pain, occasionally shooting pain, pain does not follow nerve distributionTrigger points in area of pain, usually no muscle atrophy, poor ROM in involved muscle
Chronic back painConstant dull pain, occasionally shooting pain, pain does not follow nerve distributionNo trigger points, poor ROM in involved muscle
Sciatica (Neurogenic back pain)Constant or intermittent, burning or aching, shooting or electric shock-like, may follow dermatome; leg pain > back painPossible muscle atrophy in area of pain, possible reflex changes
Complex regional pain types I and IIBurning persistent pain, allodynia, associated with immobilization/ disuse (type I) or peripheral nerve injury (type II)Early: edema, warmth, local sweating; Late: the early signs alternate with cold, pale, cyanosis, eventually atrophic changes
Postherpetic neuralgiaAllodynia, shooting, lancinating painSensory changes in the involved dermatome
Painful diabetic neuropathySymmetric numbness and burning or stabbing pain in lower extremities; allodynia may occurSensory loss in lower extremities
Phantom limb painVariable: aching, cramping, burning, squeezing or tearing sensationMay have peri-incisional sensory loss

Key: ROM = range of motion, RSD = reflex sympathetic dystrophy.

Complex regional pain type I, also known as reflex sympathetic dystrophy, and complex regional pain type II, also known as causalgia, may be seen in the emergency department (ED) 2 weeks or more after an acute injury. These disorders should be suspected when a patient presents with classic symptoms: allodynia (pain provoked with gentle touch of the skin) and a persistent burning or shooting pain. Associated signs early in the course of the disease include edema, warmth, and localized sweating.

The most important task of the emergency physician is to distinguish chronic pain from acute pain that heralds a life- or limb-threatening condition. A complete history and physical examination should confirm the chronic condition or point to the need for further evaluation when unexpected signs or symptoms are ...

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