The pain therapy visit

The pain therapy visit starts a path to fight chronic pain. It is a complex challenge in clinical practice, with important physical, psychological and social implications. The pain therapy visit is, in fact, the starting point for a correct algological diagnosis (a diagnosis made by a pain specialist) and for defining an integrated treatment plan. It can be done at the Casa di Salute Santa Lucia of the Nefrocenter group. The overall evaluation is not limited to identifying the symptom. On the contrary, it includes a global analysis of the person and of the many factors that influence how pain is perceived and processed.

The pain therapy visit: what chronic pain is

Chronic pain is not just a symptom, but an independent medical condition, recognized by the WHO and by all international guidelines. It affects more than 20% of the population in industrialized countries, with a significant impact on quality of life, productivity and healthcare spending.

The goals of the pain specialist visit

During the first visit, the pain specialist (algologist) aims to define the type of pain, which can be somatic, visceral or neuropathic. Likewise, the doctor assesses the subjective intensity of the pain and how it has changed over time, investigating the primary or secondary causes. The specialist will examine the impact of the pain on the person’s function, independence, sleep, mood and social relationships, so as to build a multimodal, personalized treatment plan.
How the pain therapy visit is structured

The medical history must be broad and targeted, and aims to identify the neuro-anatomical origin of the pain and to distinguish nociceptive components from neuropathic ones. The specialist who performs the pain therapy visit therefore proceeds to:

• Reconstruct the onset, duration, course and location of the pain.
• Assess qualitative characteristics: burning, stabbing, throbbing, heavy.
• Learn about aggravating factors (movement, cold, stress) and relieving factors (rest, heat, medications).
• Ask about previous therapies, including non-drug ones.
  Gather information on clinical and psychological comorbidities (anxiety, depression, sleep disorders).
• Obtain information on lifestyle and habits: diet, smoking, alcohol, physical activity.
• Useful tools can be pain diaries and multidimensional questionnaires (Brief Pain Inventory, McGill Pain Questionnaire).
• The specialist visually inspects the affected area and performs palpation and digital pressure to detect trigger points or hyperesthetic areas. The patient undergoes a functional neurological examination to assess sensation, reflexes and muscle strength. The specialist performs pain provocation tests (e.g. the Lasègue test for sciatica, the Phalen test for carpal tunnel).
• Objective assessment tools

Pain assessment is a crucial phase in caring for a patient with pain. Despite the subjective component of the symptom, there are validated scales and tools able to quantify, characterize and monitor the intensity of pain and its impact on quality of life. Used together, these tools help build a complete clinical profile and guide treatment choices.

• VAS – Visual Analogue Scale. It is a 10 cm horizontal line without numbers, with two ends: “No pain” on the left (0) and “The worst pain imaginable” on the right (10). The patient marks the point on the line that best represents their perception of pain at that moment.
• NRS – Numeric Rating Scale. It is a numerical scale from 0 to 10, where: 0 = no pain; 10 = unbearable pain. The patient is asked to give a number that represents the intensity of the pain felt.
• DN4 – Douleur Neuropathique en 4 questions. This is a validated clinical questionnaire for distinguishing neuropathic pain from nociceptive pain. It contains 10 items divided into two sections. The first section has subjective questions (7 items): sensations described by the patient (burning, tingling, electric shocks, numbness, etc.). The second is a physical examination (3 items): tests for allodynia, reduced touch sensation (hypoesthesia) and pinprick. It is scored so that each positive answer equals 1 point, and a score equal to or greater than 4 indicates probable neuropathic pain.
• SF-36 – Short Form 36. It is a multidimensional questionnaire made up of 36 questions, divided into 8 scales that assess different aspects of quality of life. It assesses physical functioning, role limitations due to physical health, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems and mental health.
• EQ-5D – EuroQol 5 Dimensions. This is a standardized tool for measuring health-related quality of life, particularly used in clinical and economic research. The 5 dimensions assessed are mobility, self-care, usual activities, pain/discomfort, anxiety/depression. It also includes: a visual VAS scale from 0 to 100, on which the patient rates their own perceived state of health.

Classification of pain

A correct classification is essential for effective therapy. Pain is generally divided into:

• Nociceptive pain. It results from tissue damage (e.g. osteoarthritis, fractures, trauma). Typically well localized, mechanical and predictable.
• Neuropathic pain. It originates from an injury or dysfunction of the nervous system (central or peripheral). Often burning, electric, with dysesthesias, allodynia and hyperalgesia.
• Common conditions. Postherpetic neuralgia, diabetic neuropathy, radicular syndrome (radiculopathy).
• Mixed pain. Presence of both nociceptive and neuropathic components (e.g. chronic low back pain with sciatica, post-surgical pain syndrome)
• Dysfunctional pain. Not related to obvious damage; altered central processing of pain. The common example is fibromyalgia.
• Drug therapies

Pain treatment requires a multimodal and progressive approach, following the WHO three-step ladder (for cancer pain), also adapted for non-cancer conditions.

Drug therapies are based on NSAIDs and acetaminophen (paracetamol) for mild/moderate pain. On weak opioids (tramadol, codeine) and strong opioids (morphine, oxycodone) for severe pain. In contrast, the use of co-analgesics is permitted, such as tricyclic antidepressants (amitriptyline) for neuropathic pain, anticonvulsants (pregabalin, gabapentin) and muscle relaxants for muscle spasms.

Interventional therapies

The pain therapy visit can also lead to interventional therapy with local or joint injections (infiltrations) of anesthetics and corticosteroids. Or with nerve blocks (diagnostic or therapeutic), pulsed or continuous radiofrequency on nerve ganglia and spinal neuromodulation with implanted spinal cord stimulators.
Non-drug therapies
Non-drug therapies consist of pain-relieving physical therapy, cognitive behavioral psychotherapy, relaxation and stress management techniques and, finally, acupuncture, TENS and biofeedback.
Follow-up and periodic reassessment

Regular follow-up makes it possible to monitor the effectiveness of therapy. It also makes it possible to reassess the intensity and quality of the pain and to recognize any adverse effects or new symptoms.
It therefore makes it possible to modify the treatment plan according to clinical progress.
A weekly pain diary and questionnaires at scheduled intervals (generally every 4-6 weeks) can be an important monitoring tool during the Pain Therapy Visit.

Regulations in force for the patient

Pain therapy is today a defined medical specialty in Italy, which establishes the citizen’s right to access appropriate care for pain, including the prescription of opioid drugs when necessary. The “Provisions to guarantee access to palliative care and pain therapy” is a legislative decree issued in implementation of Law No. 38 of March 15, 2010. Its purpose is to protect the citizen’s right to access appropriate care for pain, in both cancer and non-cancer settings, throughout the course of the illness.