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Abstract
Despite enormous progress in the field of pain management over the recent years, pain continues to be a highly prevalent medical condition worldwide. In the developing countries, pain is often an undertreated and neglected aspect of treatment. Awareness issues and several misconceptions associated with the use of analgesics, fear of adverse events – particularly with opioids and surgical methods of analgesia – are major factors contributing to suboptimal treatment of pain. Untreated pain, as a consequence, is associated with disability, loss of income, unemployment and considerable mortality; besides contributing majorly to the economic burden on the society and the health care system in general. Available guidelines suggest that a strategic treatment approach may be helpful for physicians in managing pain in real-world settings. The aim of this manuscript is to propose treatment recommendations for the management of different types of pain, based on the available evidence. Evidence search was performed by using MEDLINE (by PubMed) and Cochrane databases. The types of articles included in this review were based on randomized control studies, case–control or cohort studies, prospective and retrospective studies, systematic reviews, meta-analyses, clinical practice guidelines and evidence-based consensus recommendations. Articles were reviewed by a multidisciplinary expert panel and recommendations were developed. A stepwise treatment algorithm-based approach based on a careful diagnosis and evaluation of the underlying disease, associated comorbidities and type/duration of pain is proposed to assist general practitioners, physicians and pain specialists in clinical decision making.
Supplementary materials
Pain Assessment Scales
Brief Pain Inventory (BPI)
Originally developed for assessment of pain in cancer patients, the BPI has been successfully used in a variety of clinical settings.Citation1 In the BPI, severity of pain is measured across four grades, and the degree of interference of pain is evaluated across seven parameters: general activity, walking, work, mood, enjoyment of life, relationship with others and sleep.Citation2 Several modified versions of the BPI have been developed to adapt to the requirements of the target population across different geographical settings. The reliability of the Hindi version of the BPI was demonstrated in a clinical trial in North India by Saxena et al.Citation3
McGill Pain Questionnaire (MPQ)
Developed by Melzack and Torgerson in 1971,Citation4 the MPQ is a multidimensional pain assessment tool consisting of three major classes of word descriptors (total of 78 words) reflecting sensory, affective and evaluative components. It also contains a pain intensity scale ranging from one to five to rate the severity of the pain.Citation5 MPQ and the short-form MPQ (SF-MPQ) are valid and reliable tools to assess chronic pain, particularly cancer pain, in adults.Citation6–Citation9 The MPQ can also be used in the assessment of neuropathic and arthritic pain.Citation10–Citation12
Visual Analog Scale (VAS)
The VAS is a simple, easily administered, single-item tool to assess pain severity, especially in acute pain.Citation13 VAS consists of a horizontal or vertical rating scale (1–10 cm) with verbal descriptors of “no pain” and “pain as bad as it could be.” The patient is asked to mark the level of pain on the numerical scale of 1–10 cm (or 1–100 mm). Several studies have validated the use of VAS in acute and chronic pain.Citation13–Citation15
Numerical Rating Scale (NRS)
The NRS consists of a numerical scale similar to the VAS, however, with numbers marked from one to ten, ranging from “no pain” to “worst pain imaginable”. The NRS is easy to administer via paper-and-pencil, telephone, fax or any computerized system and has demonstrated superiority over the VAS across different studies,Citation16,Citation17 especially in illiterate or elderly populations.Citation18–Citation20
Verbal Rating Scale (VRS)
The VRS scale is composed of a series of adjectives along with numbers to best describe the intensity of the pain. VRS has been reported to be well correlated with the VAS, in terms of simplicity and reliability.Citation21,Citation22 However, the VRS scale has been found to be less sensitive to changes in pain intensity and is considered highly subjective.Citation22–Citation24
Faces Pain Scale (FPS)
For the self-reporting of pain severity in children, elderly and other special populations, FPS may be used. In this scale, pain is graded by means of facial expressions. FPS and the revised FPS have demonstrated reliability in predicting the severity of pain in children aged 4–8 years and in patients with cognitive impairment.Citation25–Citation28
Disease-specific assessment scales
Due to the methodological problems faced during the assessment of pain using standard tools,Citation29 disease-specific pain measurement questionnaires have been developed with an aim to correctly capture the nature and severity of pain in different pathophysiological conditions.Citation30 Use of Neuropathic Pain Scale (NPS), Neuropathic Pain Questionnaire (NPQ) and Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale is recommended to differentiate between nociceptive and neuropathic pain (A).
Cognitive and behavioral assessment scales
Pain perception is greatly influenced by the psychological and emotional status of the patient. Chronic pain may induce notable changes in the behavior, cognition and social abilities of a person. Pain is also accompanied by a state of fear, anxiety, depression and negative beliefs. These psychological traits may serve as important predictors of chronic pain and disability and may determine treatment outcomes. Therefore, a comprehensive pain management program should also involve psychological, cognitive and behavioral assessment of the patient. For this purpose, tools such as Pain Beliefs and Perceptions Inventory (PBPI), Pain Anxiety Symptoms Scale (PASS), Cognitive Evaluation Questionnaire and the Patient Attitude Questionnaire (PAQ) may be used.
Assessment in elderly or cognitively impaired patients
Patients’ self-reports of pain have been proven to be more reliable tools for accurate diagnosis of pain and treatment of pain. However, obtaining detailed self-reports in both patients with cognitive impairment and the elderly can prove to be a major challenge and, therefore, requires the use of pain assessment tools that are relatively easy and adequately describe the pain experience.Citation31 For cognitively sound older adults, the VRS, NRS or FPS may be easy and reliable to use (A), whereas in elderly with symptoms of dementia or cognitive impairment,Citation32 the Abbey’s Pain Scale, Pain Assessment in Advanced Dementia Scale (PAINAD) and Pain Assessment for the Dementing Elderly (PADE) have demonstrated reliability (A).Citation33–Citation35
Disease-specific treatment recommendations
Low-back pain (LBP)
Classification
LBP is localized to the lumbar vertebrae (L1–l5) just above the gluteus muscle.
LBP can be classified by duration as acute (<6 weeks), subacute (6–12 weeks) and chronic (>12 weeks).
LBP may be classified by cause as mechanical (strains/sprains or fractures), nonmechanical (tumors) and referred pain (kidney or gall stones or pain in nearby tissue).Citation36
LBP is classified by mechanism or “diagnostic triage” into serious spinal pathology (accompanied by “red flags”), nerve root pain/radicular pain and nonspecific LBP.
Diagnosis
Use diagnostic methods such as physical examination, X-rays, ultrasonography, computed tomography (CT) scans, magnetic resonance imaging (MRI), diskography, bone scans and blood tests (B).Citation37–Citation39
Identify “red flags”, which are signs/symptoms that are unlikely to be observed in normal LBP and generally indicate involvement of serious pathology. Identifying the red flags may help diagnose underlying chronic conditions, such as cancer (C).
Identify “yellow flags’, which represent the psychosocial barriers that may influence the subjective response to pain and which may delay recovery or indicate the risk of chronification or disability (C).
Treatment
Initiate treatment with acetaminophen and mild NSAIDs (ibuprofen, diclofenac) as first-line therapy (A).Citation40,Citation41
Second-line therapy should typically involve a combination of NSAIDs and mild opioids (codeine, tramadol) (A),Citation41,Citation42 followed by moderate-to-strong opioids (morphine, fentanyl) in severe pain.Citation42,Citation43
Third-line therapy should be initiated in case a central origin is suspected or if pain significantly affects the physical, mental and social behavior of patients; it may include anticonvulsants (gabapentin, pregabalin),Citation44 sedatives (benzodiazepines) and antidepressants (amitriptyline, nortriptyline) (A).Citation45–Citation47
Neck pain
Classification
Neck pain can be classified into four classes according to the impact of pain on body function and movement, as follows:
Pain with mobility deficits
Pain with headache
Pain with radiating pain
Pain with impaired movement.
Based on the causative mechanism, neck pain may be classified as follows:
Axial neck pain caused due to incorrect posture, physical stress or fatigue
Whiplash-associated disorder (WAD) due to pain in the muscles, joints, tendons and ligaments due to injuries or impact
Cervical radiculopathy and myelopathy due to changes to the sensory/motor function of cervical nerves or compression of spinal cord.
Diagnosis
Diagnosis should be preceded by careful evaluation of patient, the nature and extent of pain and any additional symptoms such as headaches, nausea, vomiting, vertigo or other distress (C).Citation48
Symptom assessment may help in differentiating different types of neck pains. Sharp, shooting or tingling pain may indicate a radicular origin, whereas dull, aching pain accompanied with soreness or tenderness may point toward axial pain (C).
Physical examination and self-report questionnaires are more valid assessment tools and should be preferred over diagnostic tests such as imaging, electrophysiology or blood tests, which have failed to demonstrate reliability (C).
Identify the “red flags”, which may include trauma, infections, history of pain, malignancy or major trauma, in addition to weight loss, chest pain, nausea, vomiting or fever (C).Citation49
Treatment
Exercise and physiotherapy are the most effective interventional methods with proven efficacy in neck pain (A).Citation50–Citation53
Analgesics such as acetaminophen and NSAIDs may be used for acute pain, and weak opioids may be used for chronic episodes, as first-line therapies (A).Citation49
Antidepressants, muscle relaxants and strong opioids may be reserved for refractory cases or after failure of other interventional methods (C).Citation48
Headache
Classification
According to the International Headache Society, primary headaches can be classified into migraine headaches, cluster headaches and tension-type headaches. Migraine headaches result from migraine disorders, which are further categorized as migraine with aura, migraine without aura, childhood migraine or retinal migraine depending upon the presentation.Citation54–Citation56
Secondary headaches may be caused due to an underlying disorder such as tumors.
Diagnosis
Preliminary diagnosis can be performed through symptom assessment and detailed evaluation of patient profile and history or presence of underlying disorders.
A typical migraine attack is triggered by physical activity and may be suspected if symptoms involve severe pulsating or throbbing headache on one or both sides of the head, sometimes accompanied by visual aura, sensitivity to light, nausea or vomiting. Frequently occurring migraine attacks (≥15 days per month for >3 months) despite continuing medication may be regarded as chronic migraine; the duration of headache may be 4–72 hours.
Tension-type headaches, also known as ordinary headaches, may be triggered by stress. The pain is usually bilateral, with pressing/tightening quality and is not usually accompanied by nausea, vomiting or light sensitivity. Persistent tension-type headache may indicate the presence of serious underlying disorders. These headaches may last from a few minutes to days (up to 7 days).
Cluster headaches usually involve severe unilateral pain around the eyes (orbital pain), forehead or sides of the head (temporal pain). These headaches may last for 10 minutes to 4 hours.
Diagnosis by neuroimaging techniques should be reserved for patients who have persistent pain lasting 6-month duration, often in the absence of migraine and accompanied by neurologic symptoms such as confusion, visual problems and hallucinations; also to be used in the case of patients with history of such disorders in the past (B).Citation57
Treatment
Migraine headache: begin initial treatment with oral triptans (sumatriptan or zolmitriptan), followed by the antiemetics prochlorperazine or chlorpromazine in case of nausea and vomiting (A); opioids and antidepressants may be considered as second-line therapy. In children, initial treatment may be initiated with acetaminophen and ibuprofen, followed by sumatriptan nasal spray or oral triptans (A).Citation58–Citation68
Cluster and tension-type headaches: treatment for cluster and tension-type headaches should consist of acetaminophen, low-dose NSAIDs (ibuprofen, naproxen and diclofenac), followed by an NSAID–caffeine or acetaminophen–caffeine combination as second-line therapy (A).Citation69–Citation72
Arthritic pain
Classification
Although arthritic pain involves both rheumatoid arthritis and osteoarthritis, primarily it can be classified as inflammatory arthritis, noninflammatory arthritis or arthralgia. Inflammatory pain involves the inflammation of the joints, synovial cavity or synovium. Noninflammatory arthritic pain may result from altered joint mechanics, while arthralgia represents joint tenderness in absence of inflammation, usually resulting from an underlying condition such as fibromyalgia.Citation73
Diagnosis
Carefully observe symptoms of swelling, tenderness, redness and stiffness, as well as checking joint movement, wrist movement, rotation, movement or function (B).Citation73
The diagnosis may be confirmed using bone aspiration tests and imaging tests (B).
Treatment
First-line therapy should consist of acetaminophen and oral or topical NSAIDs (ibuprofen, diclofenac or naproxen) (A).Citation73–Citation75
Second-line therapy with opioids (tramadol, morphine and oxycodone) should be considered only if the patient is unable to tolerate NSAIDs or if pain persists despite NSAID medication (A).
Table S1 Treatment recommendations
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Acknowledgments
We wish to acknowledge the efforts of other members of the Pain Working Group who contributed significantly to the development of this manuscript, namely, SS Sukumar, Hammad Usmani, Rajeev Rao, Ananth Hazare, PR Krishnan, Poorna Chandra and Umesh Gupta. Padmini Deshpande (Siro Clinpharm Pvt Ltd) provided writing assistance, and Dr Sangita Patil (SIRO Clinpharm Pvt Ltd) provided additional editorial support for the development of this manuscript. This study was funded by Johnson & Johnson Pvt Ltd, Mumbai, Maharashtra, India.
Author contributions
All authors contributed towards drafting and critically revising the review and agree to be accountable for all aspects of the work. All authors met International Committee of Medical Journal Editors criteria and all those who fulfilled those criteria are listed as authors. All authors provided direction and comments on the manuscript, made the final decision about where to publish as well as approved the submission of the manuscript to the journal.
Disclosure
Prashant Narang and Jaishid Ahdal are employees and/or shareholders of Johnson & Johnson Private Limited, Mumbai, Maharashtra, India. Gur Prasad Dureja, Rajagopalan N Iyer, and Gautam Das report no conflicts of interest in this work.