Not All Pain is Created Equal: Basic Definitions and Diagnostic Work-Up
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PRACTICAL APPROACH
Not All Pain is Created Equal: Basic Definitions and Diagnostic Work-Up Cesare Bonezzi
. Diego Fornasari . Claudio Cricelli .
Alberto Magni . Giuseppe Ventriglia
Received: July 27, 2020 / Accepted: November 4, 2020 / Published online: December 11, 2020 The Author(s) 2020
ABSTRACT Chronic pain is considered a public health priority by the World Health Organization and European health institutions. It has reached alarming proportions in terms of disability, consumption of health and social resources, and impact on primary and specialist care services. Primary care physicians are often called on to manage this condition. Chronic pain management can be challenging due to its complexity. It has traditionally been considered to include nociceptive pain that that persists longer than the normal healing time, neuropathic pain lasting more than 3 months, or a combination of these. More recently, a third descriptor, nociplastic (primary) pain, was added to classify patients with chronic pain
C. Bonezzi (&) ICS Maugeri IRCCS, Via Salvatore Maugeri 10, Pavia, Italy e-mail: [email protected] D. Fornasari Department of Medical Biotechnology and Translational Medicine, Universita` degli Studi di Milano, Via Vanvitelli 32, Milan, Italy C. Cricelli A. Magni G. Ventriglia SIMG (Italian College of General Practitioners and Primary Care), Via Del Sansovino 179, Florence, Italy
conditions such as fibromyalgia, nonspecific back pain, or mixed pain that persists or other conditions in which altered central pain modulation results in central sensitization and chronic pain in the absence of actual or threatened damage to tissues, including in the somatosensory nervous system. This document provides an overview of pain types and their underlying mechanisms. Successful pain management is facilitated by identification of the pain type. A set of diagnostic tools and a pain algorithm are presented to guide the clinician toward the correct diagnosis. The algorithm identifies cases that may require referral to a pain specialist. Once the site of origin of the pain (the ‘‘pain generator’’) is identified, or a primary pain syndrome is suspected, the accompanying article provides information and rationale to support treatment decisions based on patient characteristics.
Keywords: Chronic pain; Diagnosis; Primary care
Pain Ther (2020) 9:S1–S15
S2
Key Summary Points Chronic pain is prevalent and burdensome. This publication reviews the basic mechanisms underlying chronic pain and presents a pathway for identifying the points where painful impulses are generated or modified, the so-called ‘‘pain generators’’. We propose the SIMG 3.0 approach from the Italian Society of General Medicine to decrease misdiagnosis and promote the appropriate management of patients with chronic pain. The accompanying article covers pharmacological treatment for patients with chronic non-cancer pain, based on the underlying pain generator and patient characteristics. Patients with refractory chronic pain, especially pain with neur
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