Retrieved from: ICD-11 Beta draft Proposal Mechanism, August 19, 2015
Please refer to Beta draft Proposals Mechanism for latest iteration
http://apps.who.int/classifications/icd11/browse/proposals/f/en#/http://id.who.int/icd/entity/1
968541653?readOnly=true&action=ComplexHierarchicalChangesProposal&stableProposalG
roupId=dbb95357-5ec5-4937-a7e9-7943a6e77ca0
Proposal Status: Submitted
Complex Hierarchical Changes Proposal
2015-May-26 - 10:48 Antonia Barke
Chronic musculoskeletal pain
Detailed Explanation of the Proposal
1. ICD Concept Title
a. Fully Specified Name: Chronic Musculoskeletal Pain (new entity)
2. Classification Properties
a. Parents:
Primary:
Chronic Pain
(ICD-11 Beta http://id.who.int/icd/entity/1581976053)
Secondary:
Diseases of the musculoskeletal system and connective tissue
Diseases of the nervous system
(ICD-11 Beta http://id.who.int/icd/entity/1296093776)
Diseases of the spine
b. Type: to which of the following types does the entity belong?
Disease
Disorder/ Syndrome
c. Use:
Primary Care; Clinical; Research
and Linearization(s):
Chronic Pain, Morbidity, Disability
3. Textual Definition(s)
a. Short Definition: to be used in the print version (100 words or less)
Chronic musculoskeletal pain is chronic pain arising from bone(s), joint(s), muscle(s), spine
or related soft tissue(s). It is a heterogeneous group of chronic pain conditions originating in
persistent nociception in joint, bone, muscle and related soft tissues, with local and systemic
etiologies, but also related to deep somatic lesions. If the pain is related to visceral lesions, it
should be considered whether a diagnosis of visceral pain is appropriate; if it is related to
neuropathic mechanisms, it should be coded under neuropathic pain; and if the pain
mechanisms are non-specific, chronic musculoskeletal pain should be coded under primary
pain.
b. Detailed Definition: to be used in the online version. (no word limit)
Chronic musculoskeletal pain is chronic pain which arises from a disease process affecting
bone(s), joint(s), muscle(s), spine or related soft tissue(s). This can be typically characterized
either by persistent local or systemic inflammation, which may be due to infectious or autoimmune processes, or attributable to structural changes.
Other biomedical causes responsible for musculoskeletal pain may also apply (such as
neurologically caused muscle spasms and referred pain from deep tissues).
The musculoskeletal origin of the pain (that is, nociception in musculoskeletal tissues) should
be highly probable.
Chronic musculoskeletal pain considered to be of neuropathic origin should be coded under
neuropathic pain and non-specific musculoskeletal pain under primary pain.
If the musculoskeletal origin does not appear highly plausible and no neuropathic origin is
ascertainable; consider using codes in the section of primary pain.
c. References to the definition used:
4. Terms
a. Base Index Terms: Chronic musculoskeletal pain
b. Base Inclusion Terms:
Chronic musculoskeletal pain due to local and systemic inflammatory diseases;
Chronic musculoskeletal pain due to local and systemic inflammatory diseases due to
infection;
Chronic musculoskeletal pain due to local and systemic inflammatory diseases due to autoimmune and auto-inflammatory pathogenesis;
Chronic musculoskeletal pain due to structural osteo-articular changes;
Osteoarthrosis;
Spondylosis;
Joint damage following trauma or disease;
Chronic musculoskeletal pain referred from deep somatic lesions
c. Base Exclusion Terms:
Acute pain;
Neuropathic pain;
Primary pain;
Visceral pain
5. Body System/Structure Description
a. Body System(s)
Nervous system;
Musculoskeletal system;
Spine.
b. Body Part(s) [Anatomical Site(s)]
Bone (including vertebrae), joint, muscle, related soft tissue
c. Morphological Properties
not applicable
6. Temporal Properties
Chronic musculoskeletal pain may be experienced at any age.
Pain due to structural disorders tends to be more prevalent with increasing age.
Temporal characteristics can vary: persistent pain with slight fluctuations, recurrent pain with
pain-free intervals and persistent pain with additional pain attacks. See CM Chronic Pain.
7. Severity of Subtypes Properties See content model Chronic Pain.
8. Manifestation Properties
Symptoms and Signs: In addition to pain, symptoms may include loss of function; signs may
include those of local inflammation and deformity.
Diagnostic findings (laboratory / imaging)
Described at the level of individual conditions.
9. Causal Properties (Basic causes (if known) / causal mechanism):
The pain is caused by local or systemic inflammation, which may be due to a variety of
causes (infection, auto-immune processes) or by presumed local nociception induced by
biomechanical consequences of structural change.
In addition to such inflammatory or local biomechanical processes, further mechanisms that
may also contribute to the pain are being investigated.
10. Functioning Properties: (How a typical case with the entity is limited in daily
functioning (ICF/ see specifier)).
Musculoskeletal pain affects the locomotor system and is mainly associated with loss of
function, disability and, in appropriate populations, reduced work productivity.
The functional properties vary according to the specific disease and are specified at the level
of the particular entities. Disability and loss of function may be due to the underlying
process(es) or due to the pain (for the latter see content model Chronic Pain). Classification
by ICF (International Classification of Functioning) codes should also be invoked. (See
content model Chronic Pain).
11. Specific Condition Properties If applicable to particular groups – (biol. sex / related to
lifecycle stage).
Musculoskeletal pain is more common in women.
Several risk factors may be involved, including but not limited to:
Age
Gender
Occupation
The significance of these factors varies according to the specific entities and will be detailed
at that level.
12. Treatment Properties
Treatment may be directed towards:
Suppression of the pain (analgesia)
Suppression of the known mechanism (anti-inflammatory strategies)
Disease modification (for chronic inflammatory disorders of autoimmune or crystal
aetiology)
Structural modification (surgical approaches)
Rehabilitation and reduction of disability
13. Diagnostic Criteria (Necessary and sufficient criteria)
A) Chronic pain in muscles, bones, joints, tendons or related soft tissue.
B) At least one of B1 or B2 is fulfilled:
B1) Musculoskeletal disease with inflammation due to infection, auto-immunity, autoinflammation or metabolic disorders (crystals) is present (demonstrated by appropriate tests)
and causes the local activation of nociceptors.
B2) Musculoskeletal disease with structural / biomechanical factors (demonstrated by
appropriate tests) is present and causes the local activation of nociceptors.
References:
[1] Cohen ML: "Principles of Pain and Pain Management." Chapter 34. In Hochberg MC,
Silman AJ, Smolen JS, Weinblatt ME, Weisman MH (eds). Rheumatology, 3rd edition.
Edinburgh Mosby, 2003, pp. 369-375.
[2] Perrot S, Guilbaud G. Pathophysiology of joint pain. Rev Rhum Engl Ed. 1996;63(78):485-92.
[3] Perrot S, Bertin P. "Feeling better" or "feeling well" in usual care of hip and knee
osteoarthritis pain: determination of cutoff points for patient acceptable symptom state
(PASS) and minimal clinically important improvement (MCII) at rest and on movement in a
national multicenter cohort study of 2414 patients with painful osteoarthritis. Pain. 2013;154
(2):248-56.
Rationale
This submission represents the consensus of the Working Group Pain (Chairmen: Rolf-Detlef
Treede and Winfried Rief)
For a fuller explanation of the group and the proposed classification see:
Treede*, R.-D., Rief*, W., Barke*, A., Aziz, Q., Bennett, M.I., Benoliel, R., Cohen, M.,
Evers, S., Finnerup, N.B., First, M.B., Giamberardino, M.A., Kaasa, S., Kosek, E.,
Lavand'homme, P., Nicholas, M., Perrot, S., Scholz, J., Schug, S., Smith, B.H., Svensson, P.,
Vlaeyen, J.W., Wang, S.-J. (2015). A classification of chronic pain for ICD-11, PAIN, June
2015 (in press). DOI: 10.1097/j.pain.0000000000000160.
References
[1] Cohen ML: Principles of Pain and Pain Management. Chapter 34. In Hochberg MC,
Silman AJ, Smolen JS, Weinblatt ME, Weisman MH (eds). Rheumatology, 3rd edition.
Edinburgh Mosby, 2003, pp. 369-375. [ISBN: 9780323024044]
[2] Perrot S, Guilbaud G. Pathophysiology of joint pain. Rev Rhum Engl Ed. 1996;63(78):485-492.
[3] Perrot S, Bertin P.