How Symptom Diaries Can Improve Chronic Pain Management

Chronic pain presents complex diagnostic challenges, with comorbid illnesses, behavioral and environmental factors all playing significant roles. Stress, anxiety and depression, all common in chronic pain, can exacerbate physical symptoms (Ray et al., 2016), while factors in the work environment (ergonomics and physical labor) may contribute to chronification. Metabolic diseases (overweight, obesity, diabetes), cardiovascular conditions and the aging process itself add to complexity. Even the most diligent healthcare provider may find it difficult to gather all relevant information during the patient history and physical exam. Sometimes even a small “miss” can upset the apple cart and turn a carefully formulated treatment plan in the wrong direction.

Asking patients to keep periodic symptom diaries can help to fill in the blanks. Since diaries require a time commitment on the patient’s part, it’s best to keep these periods short: perhaps two weeks following the initial visit, and one week every month or bimonthly thereafter. The purpose is to identify triggers for pain exacerbation (acute flare-ups), as well as factors which seem to be contributing to both improvement and worsening of pain, in as granular a fashion as is practical. A standard digital or print-based form for the patient to fill in is important, and it’s essential to keep this form simple and easy to understand.

Factors to consider include:

* Time(s) of day when the pain is better or worse. Is there a consistent pattern?

* Pain triggers, including physical activity, diet and work-related factors (see above).

* Daily stress levels

* Co-morbid medical and psychological conditions that may intensify pain.

* Side effects from medications (both OTC and prescription) and drug-drug interactions.

* The sleep environment, and the patient’s sleep habits.

Following a patient’s initial responses, providers may customize forms to focus on specific areas. For example, a patient who reports high levels of daily stress, anxiety and poor sleep quality may be somaticizing, resulting in more chronic and intense pain. In this case, it would be important to gather more information about the patient’s social and family support networks, recreational activities (including exercise), socialization and relaxation strategies.

Using a symptom diary may lead to behavioral strategies that can reduce a patient’s dependence on analgesic medications while at the same time improving the patient’s internal locus of control and self-efficacy. The symptom diary becomes a collaborative tool for all members of the care team, including the patient and the patient’s family. It can also enhance motivation by demonstrating positive results from simple lifestyle improvement strategies. Finally, it enhances the therapeutic relationship via mutual rapport and respect, with patients feeling confident that they are not only heard, but listened to as well.

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