ASIPP Practice Guidelines - Pain Physician

Manchikanti et al • ASIPP Practice Guidelines
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12%
Children and
adolescents
15%
Adults
27%
Elderly
Fig. 1. Estimated average of age related prevalence of
low back pain
Reproduced with permission from Manchikanti (103)
pain intensity with moderate or severe disability, whereas
an additional 12% suffer with high pain intensity but with
a low disability. In a similar study, Cote et al (119, 120),
evaluating neck pain and its related disability, reported that
overall, 39% of the sample experienced grade I neck pain,
whereas 9% experienced grade II neck pain, and 5% had
grade III and IV neck pain (Table 2). Almost 16% of the
respondents reported having previously injured the neck
in a motor vehicle collision (119, 120).
Duration of back pain and its chronicity have been a topic
of controversy. It is believed that most of these episodes
will be short-lived, with 80% to 90% of attacks resolving
in about 6 weeks irrespective of the administration or type
of treatment; and 5% to 10% of patients developing persistent
back pain (121, 122). However, this concept has
been questioned, as the condition tends to relapse, so most
patients will experience multiple episodes. As shown in
Table 3, prevalence of low back pain ranged from 35% to
79% at 3 months and 35% to 75% at 12 months (123-127).
The studies evaluating the chronicity of low back pain estimated
the average of age related prevalence of persistent
low back pain as 12% in children and adolescents, 15% in
adults, and 27% in the elderly (Fig. 1). Bressler and colleagues
(101), in a systematic review of the literature determined
that overall prevalence of low back pain in the
elderly was 27% derived from a total elderly population
base of 17,173 with reports from 12 studies from community
population, primary care settings and from the nursing
homes with prevalence ranging from 13% to 51% (101,
109, 128-138).
Chronic Pain vs Chronic Pain Syndrome
Two major and controversial terms in today’s pain medicine
are “chronic pain,” also known as persistent pain, and
a second category known as “chronic pain syndrome,”
which is a separate and distinct condition (139-142).
Chronic pain or persistent pain persists beyond the expected
healing time of an injury or an illness, usually considered
beyond 6 months. Chronic pain may be associated with
psychological problems such as depression, generalized
anxiety disorder, and some behavioral problems. However,
chronic pain improperly diagnosed or inadequately
treated can result in deteriorating coping skills and limitations
and reduction in functional capacity. In contrast,
chronic pain syndrome is a complex condition with physical,
psychological, emotional, and social components (141,
142). Both chronic pain and chronic pain syndrome can
be defined in terms of duration and persistence of the sensation
of pain, and presence or absence of psychological
and emotional components. However, chronic pain syndrome,
as opposed to chronic pain, has the added component
of certain recognizable psychological and socioeconomic
influences, with characteristic psychological and
sociological behavior patterns inherent in chronic pain syndrome
that distinguish the two conditions (141). According
to the fifth edition of Guides to Evaluation of Permanent
Impairment published in 2000 (142), the term chronic
pain syndrome even though not official nomenclature, is
frequently used to describe an individual who is markedly
impaired by chronic pain with substantial psychological
overlay. The guides (142) also state that chronic pain syndrome
is largely a behavioral syndrome that affects a minority
of those with chronic pain. It may best be understood
as a form of an abnormal illness behavior that consists
mainly of excessive adoption of the sick role. The
guides also caution that while the term is useful in certain
situations, it does not, however, substitute for a careful diagnosis
of physiologic, psychological, and conditioning
components that comprise the syndrome. The term chronic
pain syndrome must be used with caution, as grouping pain
problems together under a general disorder may mask and
leave untreated important physiologic differences (142).
Thus, chronic pain may exist in the absence of chronic
pain syndrome, but chronic pain syndrome always presumes
the presence of chronic pain. The terminology recommended
by IASP has eliminated chronic pain syndrome
from the glossary (140). The IASP Task Force on Taxonomy
on classification of chronic pain describing definitions
of pain terms described that it is common in North
America to find patients as having “chronic pain syndrome”
(140). In this case, the Task Force believed that the words
Pain Physician Vol. 4, No. 1, 2001