title: The chronic pain conundrum: should we CHANGE from relying on past history to assessing prognostic factors?
abstract: BACKGROUND
  Despite limited empirical support, chronic pain has traditionally been defined mainly on the basis of its duration, which takes no account of the causative mechanisms or its clinical significance.
  
  
  METHODS
  For this commentary on current pain management practice, the CHANGE PAIN Advisory Board considered the evidence for adopting a prognostic definition of chronic pain. The rationale underlying this approach is to take psychological and behavioural factors into account, as well as the multidimensional nature of pain. Measures of pain intensity, interference with everyday activities, role disability, depression, duration and number of pain sites are used to calculate a risk score, which indicates the likelihood of a patient having pain in the future. The consistency of a prognostic definition with the concept of integrated patient care was also considered.
  
  
  RESULTS
  When this method was compared with the number of pain days experienced over the previous 6 months--in patients with back pain, headache or orofacial pain--it was a better predictor of clinically significant pain 6 months later for all three pain conditions. Further evidence supporting this approach is that several factors other than the duration of pain have been shown to be important prognostic indicators, including unemployment, functional disability, anxiety and self-rated health. The use of a multifactorial risk score may also suggest specific measures to improve outcomes, such as addressing emotional distress. These measures should be undertaken as part of an integrated pain management strategy; chronic pain is a biopsychosocial phenomenon and all aspects of the patient's pain must be dealt with appropriately and simultaneously for treatment to be effective.
  
  
  CONCLUSIONS
  The implementation of a prognostic definition and wider adoption of integrated care could bring significant advantages. However, these measures require improved training in pain management and structural revision of specialist facilities, for which political support is essential.
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA. jpjmd@msn.com
authors.forename: Joseph
authors.initials: J
authors.lastname: Pergolizzi
authors.forename: Karsten
authors.initials: K
authors.lastname: Ahlbeck
authors.forename: Dominic
authors.initials: D
authors.lastname: Aldington
authors.forename: Eli
authors.initials: E
authors.lastname: Alon
authors.forename: Beverly
authors.initials: B
authors.lastname: Collett
authors.forename: Flaminia
authors.initials: F
authors.lastname: Coluzzi
authors.forename: Frank
authors.initials: F
authors.lastname: Huygen
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Jaksch
authors.forename: Magdalena
authors.initials: M
authors.lastname: Kocot-Kępska
authors.forename: Ana Cristina
authors.initials: AC
authors.lastname: Mangas
authors.forename: Cesar
authors.initials: C
authors.lastname: Margarit
authors.forename: Philippe
authors.initials: P
authors.lastname: Mavrocordatos
authors.forename: Bart
authors.initials: B
authors.lastname: Morlion
authors.forename: Gerhard
authors.initials: G
authors.lastname: Müller-Schwefe
authors.forename: Andrew
authors.initials: A
authors.lastname: Nicolaou
authors.forename: Concepción
authors.initials: C
authors.lastname: Pérez Hernández
authors.forename: Patrick
authors.initials: P
authors.lastname: Sichere
authors.forename: Giustino
authors.initials: G
authors.lastname: Varrassi
mesh_terms: D059350:Chronic Pain / Q000188:drug therapy / Q000523:psychology* / Q000628:therapy*; D006801:Humans; D059408:Pain Management / Q000379:methods*; D010147:Pain Measurement / Q000379:methods; D011379:Prognosis