Quantitative Sensory Testing in pain assessment and treatment. Brief review and algorithmic management proposal | Revista Española de Anestesiología y Reanimación (English Edition)

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Brief review and algorithmic management proposal" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "187" "paginaFinal" => "194" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Avellanal, I. Riquelme, G. Díaz-Regañón" "autores" => array:3 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Avellanal" "email" => array:1 [ 0 => "mavellanal@telefonica.net" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "I." "apellidos" => "Riquelme" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "G." 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Breve revisión y propuesta de protocolización de empleo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 570 "Ancho" => 1500 "Tamanyo" => 99683 ] ] "descripcion" => array:1 [ "en" => "Pinprick test. Complete set of 7 calibrated devices for the pinprick test with metronome. On the left, Neuropen device® (Owen-Mumford Ltd., Oxford, Great Britain)." ] ] ] "textoCompleto" => "IntroductionQuantitative sensory testing (QST) is a psychophysical method to quantify the body's somatosensory function based on its response to controlled mechanical (touch, pressure, vibration), thermal (cold, warm) or electrical stimuli.It is based on the Weber–Fechner law that establishes a logarithmic relationship between the intensity of a stimulus and its perception, in other words, the discrimination threshold increases in direct proportion to the intensity of the stimulus.<a class="elsevierStyleCrossRef" href="#bib0125">1</a>Early experiments published in the 1940s and 1950s used different types of scales to quantify pain. In recent years, devices and tests have been developed that allow us to explore the physiological and pathophysiological aspects of pain in a more objective way by evaluating the activity of the small nociceptive nerve fibres that account for up to 80% of the peripheral nervous system that cannot be measured with other conventional studies such as evoked potentials, electromyograms, or electroneurograms.After successful laboratory studies, QST is now being introduced into clinic practice in Pain Units in countries such as the United States or Germany, and the first standard protocol was developed in 2006 by the German Research Network on Neuropathic Pain.<a class="elsevierStyleCrossRefs" href="#bib0130">2,3</a>. This formed the basis for the first consensus on the clinical use of QST drawn up by the Neuropathic Pain Special Interest Group (NeuPSIG) of the International Association for the Study of Pain (IASP) in 2013.<a class="elsevierStyleCrossRef" href="#bib0140">4</a> It is now increasingly common for studies to use some QST measures (notable pressure algometry or von Frey filaments) with standard pain scales to heighten objectivity.<a class="elsevierStyleCrossRef" href="#bib0145">5</a>QST objectifies the response of the nociceptive system in patients with acute or chronic localized pain, such as neuropathic pain (neuralgia, post-chemotherapy neuropathies, diabetics, radiculopathies), osteomuscular pain (severe osteoarthritis, lumbago, etc.), headaches, and generalized pain (fibromyalgia, polyarthritis). It helps maximize objectivity when evaluating response to therapy (pharmacological, interventional, physiotherapy and psychotherapy), and the results of baseline QST can even be used to predict the best therapeutic approach. Some pain patterns are associated with certain pathologies, such as postherpetic neuralgia or fibromyalgia. The phenomenon of central sensitization, which is responsible for the chronification and symptomatic aggravation of many painful processes, particularly chronic postoperative pain, can also be studied with this methodology.In this study we discuss the role of QST in anaesthesiology and pain management, and describe the basic principles, utility and indications for the technique, the devices and tests used, and how they are applied.ClassificationTwo fundamental groups of tests are used in the study of pain:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">a.Static: these show “how the patient perceives pain”. The tests explore:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010">–Allodynia (mechanical, thermal). In this case it is important to mark out the area to be tested.</li><li class="elsevierStyleListItem" id="lsti0015">–Perception thresholds (tactile/mechanical, vibration, temperature).</li><li class="elsevierStyleListItem" id="lsti0020">–Pain thresholds (mechanical, pressure, warm, cold, electrical).</li></ul></li><li class="elsevierStyleListItem" id="lsti0025">b.Dynamic: these show how pain modulation systems work. The tests explore:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030">–Temporal summation (wind up). A repeated painful stimulus causes increased pain perception.</li><li class="elsevierStyleListItem" id="lsti0035">–Conditioned pain modulation (a distant pain stimulus reduces perception of the original pain). This explores the integrity of the descending inhibitory pathway.</li><li class="elsevierStyleListItem" id="lsti0040">–Central sensitization: central sensitization is induced with a series of high-frequency electrical stimuli. This usually subsides within 24h, but it can persist for several days or weeks in 20% of the healthy population.</li></ul></li></ul>MaterialThe minimum requirements for a basic QST lab are as follows.Calibrated brush for the study of dynamic mechanical allodynia (Brush-05®, Somedic SenseLab AB, Sösdala, Sweden)A calibrated brush or mini-brush consisting of a mixture of 20 natural and synthetic microfilaments measuring 20mm in length; the tip of the brush measures 15mm across, and each filament is 5mm thick. The average pressure of the brush against the skin is 100mN (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>It can be replaced in practice by cotton wool or cotton buds (Q-tips), which must be used in continuous contact with the skin in an area measuring 1–2cm.Von Frey filamentsA complete set of 20 plastic monofilaments numbered from 1.65 to 6.65 (the logarithm 10 times the force in milligrams required to bow the monofilament) for the Semmes–Weinstein monofilament test.<a class="elsevierStyleCrossRef" href="#bib0150">6</a> The filament are applied perpendicularly, and between 0.0045 and 448g of pressure are needed to bend the filament (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The filaments eventually lose consistency with use, so they must be replaced periodically. In some models only the filament needs to be replaced at a reasonable price, not the holder.Devices for the «Pinprick» testIdeally, a set of 7 pinprick stimulators calibrated against their own weight should be used to administer sharp stimuli with an applied force of between 8 and 512mN on a contact surface measuring 0.2mm.<a class="elsevierStyleCrossRefs" href="#bib0130">2,7</a> These instruments are very delicate and expensive, and can easily lose calibration if used incorrectly. They are used to measure mechanical pain thresholds and temporal summation (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>There is a very inexpensive and less accurate device (it is not calibrated with its own weight, but depends on the force applied by the clinician against a spring) that applies a pressure of approximately 390mN (40g), which is usually the mean force needed to detect painful mechanical stimulation in most patients (Neuropen®, Owen-Mumford Ltd., Oxford, Great Britain). It also includes a 10g monofilament for measuring mechanical sensitivity.<a class="elsevierStyleCrossRef" href="#bib0160">8</a>Pressure algometryMany different algometers, both analogue and digital, are available. Some have built-in data collection programmes and real-time graphics that improve the accuracy of the different tests applied by regulating the progressive application of pressure over time.They usually consist of a 1cm2 circular surface probe that can apply pressures of up to 200N/cm2 (about 20K/cm2) with progressive ramp increments (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<elsevierMultimedia ident="fig0020"></elsevierMultimedia>Thermal sensitivity evaluation devices or hot/cold thermodesThese are the most expensive instruments in the laboratory. There are 2 types of thermodes: those that can detect warm and cold perception thresholds, as well as warm pain thresholds; and more expensive models that can also study more complex cold pain thresholds.These devices consist of probes or thermodes of different sizes (even for dental use) which, in contact with the skin, apply ramp or progressive temperature stimuli that can range from 0° C to 60°C, and usually start at 32°C. They can also administer discontinuous cold/warm stimuli to measure discrimination.They operate on the basis of the Peltier thermoelectric effect by which a temperature difference is directly converted to electric voltage and vice versa. This effect is also used in other fields to warm or cool objects.<a class="elsevierStyleCrossRef" href="#bib0165">9</a>The devices currently available on the market are:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0045">–Modular Sensory Analyzer Thermal Stimulator® (Somedic SenseLab AB, Sösdala, Sweden). This is most comprehensive, sophisticated and accurate device. It is usually only used in universities or other academic facilities equipped with experimental laboratories. It costs over €25,000, but curiously enough, does not have a Food and Drug Administration seal for sale in the EU.</li><li class="elsevierStyleListItem" id="lsti0050">–Medoc Q-sense® (Medoc Ltd, Ramat Yishay, Israel). There are two models, an inexpensive one that does not include detection of cold pain thresholds, and a more sophisticated one that does. Most are compatible with functional MRI studies. The Q-sense® can be connected to a computer for viewing data and generating clinical reports. Prices start at €14,000.</li><li class="elsevierStyleListItem" id="lsti0055">–Thermal Cutaneous Stimulator-TCS® (QST.Lab, Strasbourg, France). This surprisingly simple, intuitive, portable device was launched less than a year ago. It can be used for all kinds of studies, and parameters can easily be customized; however, it does not yet have software adapted for clinical use. The device costs around €17,000.</li><li class="elsevierStyleListItem" id="lsti0060">–NerveCheck® (Phi Med Europe, Barcelona, Spain). Developed in Spain to study diabetic neuropathy (includes vibrometer), this is the most inexpensive and easy-to-use of all such devices. It does not include detection of cold pain thresholds,<a class="elsevierStyleCrossRef" href="#bib0170">10</a> and is the only device to use the method levels instead of ramped stimulation. Although this may be seen as a disadvantage, many researchers believe it to be more reliable and precise because it eliminates the response time variable that varies greatly depending on age, attention span, etc.<a class="elsevierStyleCrossRef" href="#bib0175">11</a> It includes built-in software that plots the parameters on a graph, currently costs less than €2000, and it is a good option for start-up laboratories. The only drawback is the cost of replacement sensors.</li></ul>Along with the aforementioned devices, there is a simple instrument that can quickly detect anomalies in C and A-delta fibres over large body areas by discriminating between differences in temperature. This is the Rolltemp II® (Somedic SenseLab AB, Sösdala, Sweden), which consists of 2 metal rollers measuring 15mm across that are warmed in a special apparatus to 40°C (red) and 25°C (blue) – a difference of −7 and +8°C from the normal average body temperature of 32°C, which is sufficient to detect normal and abnormal temperature sensitivity. The device can be used to detect the level of subarachnoid or epidural anaesthesia in the operating room or the level of spinal damage in the emergency room (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).<elsevierMultimedia ident="fig0025"></elsevierMultimedia>VibrometersThese are used to evaluate vibration detection thresholds. Most authors use calibrated tuning forks sets or a single adjustable frequency tuning fork (Rydel-Seiffer scale, 64Hz, 8/8 scale), which are very affordable. Descending stimuli are applied to a bony surface (styloid process on the wrist or malleolus on the foot).The NerveCheck® (Phi Med Europe, Barcelona, Spain) includes a digital vibrometer.Although vibrometers are included in protocols, their practical use in pain management is very limited and they are not usually included in clinical studies. In patients with diabetic neuropathy, however, a higher vibration detection threshold has been associated with an exponential increase in complications related to ulcers and amputations.<a class="elsevierStyleCrossRef" href="#bib0180">12</a>Other devicesOther devices can complement the information obtained and extend the scope of study, for example, by exploring the involvement of the sympathetic nervous system in pain. In our laboratory, for example, we use computerized infrared thermal imaging (FLIR Systems Inc., Wilsonwille, Oregon, USA) together with a laser-doppler tissue perfusion monitor (Transonic Systems Inc., Ithaca, NY, USA).Some study protocols aimed at inducing central sensitization explore the response to different intensities of transcutaneous electrical nerve stimulation. Many of the neurostimulators used by anaesthesiologists to explore neuromuscular relaxation and some of those used to locate peripheral nerves can be used for this purpose.The International Association for the Study of Pain 2013 consensus documentQST studies must be performed systematically. The variety of methodologies used by different groups involved in different lines of research can be confusing, and many of them are impractical in clinical practice. The consensus document published by the International Association for the Study of Pain (IASP),<a class="elsevierStyleCrossRef" href="#bib0140">4</a> based on the protocol developed by the German Neuropathic Pain Research Network,<a class="elsevierStyleCrossRef" href="#bib0135">3</a> is currently the best reference. These are the basic recommendations:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0065">–Test order:<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0070">1.From least to most painful: mechanical detection thresholds-vibration threshold-temperature detection thresholds (warm/cold)-temperature pain thresholds-mechanical pain thresholds-pressure pain thresholds.</li><li class="elsevierStyleListItem" id="lsti0075">2.Observe wait-times between tests. Dynamic studies or special protocols should be administered after a reasonable rest.</li></ul></li><li class="elsevierStyleListItem" id="lsti0080">–They can either be performed using the method of limits, where the stimulus is increased or decreased until a response is elicited from the patient (verbal or pressing a button), or using the method of levels, which is not based on reaction time, and is more time-consuming.</li><li class="elsevierStyleListItem" id="lsti0085">–Null stimuli should be included (although this is not mandatory).</li><li class="elsevierStyleListItem" id="lsti0090">–Perform at least 3 determinations per patient for threshold detection.</li><li class="elsevierStyleListItem" id="lsti0095">–Area of application:</li></ul><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0100">1.Peripheral polyneuropathy: as distal as possible (tip of the index finger).</li><li class="elsevierStyleListItem" id="lsti0105">2.Localized pain: area of most pain and the contralateral area or, where appropriate, compare with another healthy area. Always start with non-painful areas.</li><li class="elsevierStyleListItem" id="lsti0110">3.Generalized chronic pain (variable, depending on the purpose of the study). One of the most widely used protocols is the evaluation of the bilateral trapezius and bilateral anterior tibial crest.</li></ul><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0115">–Take the published normal reference values into account (these vary greatly according to sex, race, etc.).<a class="elsevierStyleCrossRef" href="#bib0135">3</a></li><li class="elsevierStyleListItem" id="lsti0120">–Duration: 30–90min, depending on complexity.</li></ul>Study algorithmDespite these recommendations, it is still difficult to adapt all this information to clinical practice. In our group, we use the following protocol based on IASP recommendations:<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0125">1.Mark the painful areas indicated by the patient and choose the generalized or localized pain protocol. Give the patient time to acclimitise, explain the study to them and let them relax in a neutral, quiet room.</li><li class="elsevierStyleListItem" id="lsti0130">2.Dynamic mechanical allodynia (cotton wool/Brush-05®/cotton swab). Draw the outline of the areas of allodynia. Determine allodynia yes/no and the area. Strictly speaking, each area should be tested up to 5 times, and if response is positive with the calibrated brush, also try with the tip of a cotton swab, which should apply a much lower pressure (about 3mN).<a class="elsevierStyleCrossRef" href="#bib0155">7</a></li><li class="elsevierStyleListItem" id="lsti0135">3.Mechanical perception thresholds. Determine the level of mechanical perception in each area using von Frey filaments (Semmes–Weinstein test) in increasing and decreasing order. The average value of 3–5 measurements is chosen.</li><li class="elsevierStyleListItem" id="lsti0140">4.Vibration thresholds. This is only used in diabetic or post-chemotherapy neuropathy.</li><li class="elsevierStyleListItem" id="lsti0145">5.Cold/warm detection thresholds. Increments and decrements from 32°C (minimum 3°C, maximum 51.5°C) to 1°C/s; the method of limits can also be used. The mean of 3 measurements is taken per area, 30–90min apart, never on the same area, but in close proximity to it.</li><li class="elsevierStyleListItem" id="lsti0150">6.Mechanical perception thresholds. The expensive and delicate set of calibrated pinpricks should be replaced with medium to high thickness von Frey filaments that also reach 512mN of maximum pressure (pressure should vary between 8 and 512mN). The average of 3–5 series in ascending and descending order is taken.</li><li class="elsevierStyleListItem" id="lsti0155">7.Pressure pain thresholds. We usually use the method of limits in this test. Apply increments of 30–50N/m2 per second (30kPa=30N/m2=30kg/cm2=4.4 pounds). The mean of 3 measurements per area at 20min intervals, never in the same area but in close proximity to it, is taken. Apply a maximum pressure of 1000N/m2, and if no pain is elicited, this is noted as a threshold of pain.</li><li class="elsevierStyleListItem" id="lsti0160">8.Cold/hot pain thresholds. Only warm pain thresholds can be measured. Increments and decrements from 32°C (minimum 3°C, maximum 51.5°C) to 1°C/s; the method of limits can also be used. The mean of 3 measurements is taken per area 30–90min apart, never on the same area, but in close proximity to it.</li><li class="elsevierStyleListItem" id="lsti0165">9.Conditioned pain modulation. Primarily used in chronic generalized pain or fibromyalgia to explore the descending inhibitory pathway.<a class="elsevierStyleCrossRef" href="#bib0185">13</a> A remote area, usually the arm or hand, receives a painful stimulus (ice cube<a class="elsevierStyleCrossRef" href="#bib0190">14</a> or ischaemia cuff, maximum 10min at 200mmHg or up to VAS 6). At the same time, the pressure pain threshold test is repeated in the affected area.</li><li class="elsevierStyleListItem" id="lsti0170">10.Temporal summation (wind up). A mechanical stimulus (pinprick or filament) above the pain threshold (almost always around 256mN or higher) is chosen. The stimulus is applied once and the patient is asked to rate it from 1 to 10 (or 1–100). After 10 stimuli applied at regular intervals (1 stimulus×second, or even using a metronome) on the same localized 1cm2 area, ask the patient to rate the last stimulus. Under normal conditions, this will be at least 20% higher than the baseline measurement. The difference between the last score and the baseline value is the wind-up.<a class="elsevierStyleCrossRef" href="#bib0195">15</a></li><li class="elsevierStyleListItem" id="lsti0175">11.Central sensitization induction. With a neurostimulator located in the forearm, the threshold of a high frequency electrical stimulus (100Hz) is first determined by increasing and decreasing the stimulus (average of 3–5 measurements). Next, stimuli of the same frequency but 10 times the intensity of the detection threshold are applied 5 times for 1s (pulses of 2ms with 10s intervals between each stimulus). After 10min, the threshold tests for mechanical pain and for electrical stimulation are started and repeated at 2, 4, 8, 24, 48 and 72h. A significant decrease in pain thresholds will be observed due to the appearance of central sensitization mediated by the mechanism known as long-term enhancement of pain perception after short, high-frequency stimuli applied to the posterior medullary horn. This phenomenon usually subsides after 24h, but in predisposed individuals it can last for days, and puts them at greater risk of developing symptoms such as chronic postoperative pain.<a class="elsevierStyleCrossRef" href="#bib0200">16</a></li><li class="elsevierStyleListItem" id="lsti0180">12.Supra-threshold stimuli and pain tolerance thresholds or pain withdrawal reflex. These are rarely used, except in experimental studies. They require specific consent and must be performed outside the context of routine studies. The technique involves applying stimuli, generally pressure, temperature or electrical, above the pain threshold to assess hyperalgesia, and even up to the limit of the patient's tolerance in the case of withdrawal reflex.</li></ul>Specific study designA vast array of methodologies are available for particular disease. To simplify, we propose the following battery of tests for the most frequent cases, taking into account the recommendations of the IASP.<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0185">1.Generalized chronic pain.<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0190">–Area: bilateral trapezium (10cm from acromion) and anterior tibial (10cm from lower border of patella). Requires a pain-free control area.</li><li class="elsevierStyleListItem" id="lsti0195">–Test: mechanical (allodynia, perception and pain thresholds), pressure (pain threshold), temperature (cold/warm and warm pain perception thresholds).</li><li class="elsevierStyleListItem" id="lsti0200">–Conditioned pain modulation.</li></ul></li><li class="elsevierStyleListItem" id="lsti0205">2.Localized pain.<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0210">–Mark the area of pain and contralateral area.</li><li class="elsevierStyleListItem" id="lsti0215">–Test: mechanical (allodynia, perception and pain thresholds), pressure (pain threshold), temperature (cold/warm and warm pain perception thresholds).</li><li class="elsevierStyleListItem" id="lsti0220">–Temporary summation.</li></ul></li><li class="elsevierStyleListItem" id="lsti0225">3.Perineal pain.<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0230">–Mark the area of pain and contralateral area. If bilateral, compare with trapezoids.</li><li class="elsevierStyleListItem" id="lsti0235">–Test: mechanical (allodynia, perception and pain thresholds), pressure (pain threshold), temperature (cold/warm and warm pain perception thresholds).</li><li class="elsevierStyleListItem" id="lsti0240">–Temporary summation.</li><li class="elsevierStyleListItem" id="lsti0245">–Conditioned pain modulation in vulvodynia.</li></ul></li><li class="elsevierStyleListItem" id="lsti0250">4.Headache. In migraines, test the frontal, temporal and occipital (midline between mastoids and inion) and contralateral areas. In case of holocranial headache, compare with tibial crest or trapezius (if no pain is reported at that level).<a class="elsevierStyleCrossRef" href="#bib0205">17</a><ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0255">–Test: mechanical (allodynia, perception and pain thresholds), pressure (pain threshold), temperature (cold/warm and warm pain perception thresholds).</li><li class="elsevierStyleListItem" id="lsti0260">–Temporary summation.</li><li class="elsevierStyleListItem" id="lsti0265">–Conditioned pain modulation.</li></ul></li></ul>Sympathetic response in the palmar region can be tested in each case using a laser-Doppler probe and computerized infrared thermography to measure microcirculation.Predictive value of QST studiesAlthough there are no universal rules, certain data from QST studies are associated with certain pathophysiological mechanisms, clinical diagnoses, risk of complications, or response to certain treatments. They cannot be used to achieve a firm diagnosis, but can give an orientation.<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0270">a.Risk of developing chronic pain<a class="elsevierStyleCrossRef" href="#bib0210">18</a>:<ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0275">–Alteration of conditioned pain modulation (generalized chronic pain, fibromyalgia, etc.).</li><li class="elsevierStyleListItem" id="lsti0280">–Delayed recovery after central sensitization (chronic post-operative pain).</li></ul></li><li class="elsevierStyleListItem" id="lsti0285">b.Efficacy of pharmacological treatments<a class="elsevierStyleCrossRefs" href="#bib0210">18,19</a>:<ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0290">–Low pressure pain threshold and moderate allodynia (capsaicin).<a class="elsevierStyleCrossRef" href="#bib0220">20</a></li><li class="elsevierStyleListItem" id="lsti0295">–Pinprick test positive for mechanical hyperalgesia (pregabalin).</li><li class="elsevierStyleListItem" id="lsti0300">–Hyperalgesia with preserved sensory functions (irritable nociceptor syndrome) (oxcarbazepine).</li><li class="elsevierStyleListItem" id="lsti0305">–Alteration of conditioned pain modulation (duloxetine).</li></ul></li><li class="elsevierStyleListItem" id="lsti0310">c.Mechanisms involved<a class="elsevierStyleCrossRef" href="#bib0225">21</a>:<ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0315">–Low mechanical and thermal sensory perception (deafferentation).</li><li class="elsevierStyleListItem" id="lsti0320">–Thermal hyperalgesia, no sensory alteration (peripheral sensitization).</li><li class="elsevierStyleListItem" id="lsti0325">–Mechanical hyperalgesia, slight decrease in thermal sensitivity, facilitated temporal summation (central sensitization).<a class="elsevierStyleCrossRef" href="#bib0230">22</a></li></ul></li></ul>Discussion and conclusionsQST studies give clinicians a more accurate and objective approach to nociceptive pain. The knowledge gained through basic laboratory research has now been translated into clinical practice in many of our neighbouring countries.Despite IASP recommendations, the proliferation of methodologies and variants in the literature can be confusing to clinicians entering this field for the first time.Mastering QST requires many hours of study, training and practice in order to fully understand the different techniques and adapt them to our clinical practice. However, once the methodology of each test has been well defined, they can be simply and routinely applied. Therefore, a good strategy would be to start with simple devices such as von Frey filaments or pressure algometers, and once familiarized with these, start incorporating allodynia records, perception thresholds, and mechanical and pressure pain perception in clinical studies of acute or chronic pain, along with standard pain scales (VAS, Brief Pain Inventory, etc.). In patients with neuropathic pain, QST studies have shown better correlation with the severity of neuropathy than different disease-specific scales.<a class="elsevierStyleCrossRef" href="#bib0235">23</a> It would be advisable to include these tests in the training curriculum of anaesthesiology and critical care residents.The most comprehensive and complex QST studies should be included in the services offered by highly specialized Pain Units, and can be used for at least three purposes:<ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0330">a.In clinical trials designed to evaluate the effectiveness of new drugs or therapies.</li><li class="elsevierStyleListItem" id="lsti0335">b.To improve our understanding of the pathophysiological mechanisms of complex pain.</li><li class="elsevierStyleListItem" id="lsti0340">c.To draw up reports of patients with primary chronic pain that can be used in forensic medicine. The growing prevalence of primary chronic pain was highlighted in the latest International Classification of Diseases (ICD-11) proposed by the IASP and published by the World Health Organization (WHO) in 2019.<a class="elsevierStyleCrossRef" href="#bib0240">24</a></li></ul>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1330889" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1226234" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1330888" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1226235" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Classification" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Material" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Calibrated brush for the study of dynamic mechanical allodynia (Brush-05®, Somedic SenseLab AB, Sösdala, Sweden)" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Von Frey filaments" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Devices for the «Pinprick» test" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Pressure algometry" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Thermal sensitivity evaluation devices or hot/cold thermodes" ] 5 => array:2 [ "identificador" => "sec0045" "titulo" => "Vibrometers" ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Other devices" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "The International Association for the Study of Pain 2013 consensus document" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Study algorithm" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Specific study design" ] 10 => array:2 [ "identificador" => "sec0070" "titulo" => "Predictive value of QST studies" ] 11 => array:2 [ "identificador" => "sec0075" "titulo" => "Discussion and conclusions" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-09-06" "fechaAceptado" => "2020-01-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1226234" "palabras" => array:4 [ 0 => "Pain" 1 => "Quantitative sensory testing" 2 => "Neuropathic pain" 3 => "Pain assessment" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1226235" "palabras" => array:4 [ 0 => "Dolor" 1 => "Estudio sensitivo cuantitativo" 2 => "Dolor neuropático" 3 => "Evaluación del dolor" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Quantitative sensory testing (QST) is used to globally analyze the nociceptive system in order to obtain a more objective understanding of pain perception. In recent years, QST has become a common tool in many pain clinics and anesthesiology departments worldwide. In 2013, the Neuropathic Pain Special Interest Group of the IASP put forward the first recommendations for conducting QST in clinical practice and research. However, the wide variety of QST methodologies and standards in the literature make it difficult to generalize the used of this tool in clinical practice. In this study, we present the basic concepts of QST, the type of tests and devices used, how they are applied, and the role of QST in anesthesiology and pain management." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Los estudios sensitivos cuantitativos, más conocidos por sus siglas en inglés QST (Quantitative Sensory Testing), son un conjunto de pruebas que permiten evaluar de forma integral el sistema nociceptivo y obtener información más objetiva de cómo se percibe el dolor. En los últimos años se ha convertido en una herramienta de uso común en muchas Unidades del Dolor y Departamentos de Anestesiología de muchos países. En 2013, el Grupo de Dolor Neuropático de la IASP propuso las primeras recomendaciones para su aplicación en la práctica clínica y en investigación. No obstante, existen multitud de variantes metodológicas publicadas, con estándares no armonizados, que hacen que resulte complejo introducirse en este campo y generalizar su uso. En este trabajo intentamos presentar los fundamentos, tipos de test y dispositivos, metodología de aplicación y su utilidad en Anestesiología y Tratamiento del Dolor." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Avellanal M, Riquelme I, Díaz-Regañón G. Test sensitivos cuantitativos («Quantitative Sensory Testing») en el diagnóstico y tratamiento del dolor. Breve revisión y propuesta de protocolización de empleo. Rev Esp Anestesiol Reanim. 2020;67:187–194." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0090" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 601 "Ancho" => 800 "Tamanyo" => 65170 ] ] "descripcion" => array:1 [ "en" => "Calibrated brush for evaluating dynamic mechanical allodynia (Brush-05®, Somedic SenseLab AB, Sösdala, Sweden)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 601 "Ancho" => 800 "Tamanyo" => 58681 ] ] "descripcion" => array:1 [ "en" => "Complete set of calibrated von Frey filaments for the Semmes–Weinstein monofilament test." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 570 "Ancho" => 1500 "Tamanyo" => 99683 ] ] "descripcion" => array:1 [ "en" => "Pinprick test. Complete set of 7 calibrated devices for the pinprick test with metronome. On the left, Neuropen device® (Owen-Mumford Ltd., Oxford, Great Britain)." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 602 "Ancho" => 800 "Tamanyo" => 65153 ] ] "descripcion" => array:1 [ "en" => "Digital pressure algometer." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 601 "Ancho" => 800 "Tamanyo" => 74446 ] ] "descripcion" => array:1 [ "en" => "Medoc Q-sense® warm/cold thermode (Medoc Ltd., Israel) with on-screen graphic record. Rolltemp II® warm/cold rollers (Somedic SenseLab AB, Sösdala, Sweden) in upper right corner." ] ] 5 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.doc" "ficheroTamanyo" => 115712 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Psychophysical scaling: an overview" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "G. 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Quantitative Sensory Testing in pain assessment and treatment. Brief review and algorithmic management proposal

Test sensitivos cuantitativos («Quantitative Sensory Testing») en el diagnóstico y tratamiento del dolor. Breve revisión y propuesta de protocolización de empleo

M. Avellanala,b,

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mavellanal@telefonica.net

Corresponding author.

, I. Riquelmea,b, G. Díaz-Regañóna,b

a Unidad del Dolor, Hospital Universitario Sanitas La Moraleja, Madrid, Spain

b Consultores en Dolor, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Quantitative sensory testing &#40;QST&#41; is a psychophysical method to quantify the body&#39;s somatosensory function based on its response to controlled mechanical &#40;touch&#44; pressure&#44; vibration&#41;&#44; thermal &#40;cold&#44; warm&#41; or electrical stimuli&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">It is based on the Weber&#8211;Fechner law that establishes a logarithmic relationship between the intensity of a stimulus and its perception&#44; in other words&#44; the discrimination threshold increases in direct proportion to the intensity of the stimulus&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Early experiments published in the 1940s and 1950s used different types of scales to quantify pain&#46; In recent years&#44; devices and tests have been developed that allow us to explore the physiological and pathophysiological aspects of pain in a more objective way by evaluating the activity of the small nociceptive nerve fibres that account for up to 80&#37; of the peripheral nervous system that cannot be measured with other conventional studies such as evoked potentials&#44; electromyograms&#44; or electroneurograms&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">After successful laboratory studies&#44; QST is now being introduced into clinic practice in Pain Units in countries such as the United States or Germany&#44; and the first standard protocol was developed in 2006 by the German Research Network on Neuropathic Pain&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">2&#44;3</span></a>&#46; This formed the basis for the first consensus on the clinical use of QST drawn up by the Neuropathic Pain Special Interest Group &#40;NeuPSIG&#41; of the International Association for the Study of Pain &#40;IASP&#41; in 2013&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> It is now increasingly common for studies to use some QST measures &#40;notable pressure algometry or von Frey filaments&#41; with standard pain scales to heighten objectivity&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">QST objectifies the response of the nociceptive system in patients with acute or chronic localized pain&#44; such as neuropathic pain &#40;neuralgia&#44; post-chemotherapy neuropathies&#44; diabetics&#44; radiculopathies&#41;&#44; osteomuscular pain &#40;severe osteoarthritis&#44; lumbago&#44; etc&#46;&#41;&#44; headaches&#44; and generalized pain &#40;fibromyalgia&#44; polyarthritis&#41;&#46; It helps maximize objectivity when evaluating response to therapy &#40;pharmacological&#44; interventional&#44; physiotherapy and psychotherapy&#41;&#44; and the results of baseline QST can even be used to predict the best therapeutic approach&#46; Some pain patterns are associated with certain pathologies&#44; such as postherpetic neuralgia or fibromyalgia&#46; The phenomenon of central sensitization&#44; which is responsible for the chronification and symptomatic aggravation of many painful processes&#44; particularly chronic postoperative pain&#44; can also be studied with this methodology&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this study we discuss the role of QST in anaesthesiology and pain management&#44; and describe the basic principles&#44; utility and indications for the technique&#44; the devices and tests used&#44; and how they are applied&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Classification</span><p id="par0035" class="elsevierStylePara elsevierViewall">Two fundamental groups of tests are used in the study of pain&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall">Static&#58; 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these show how pain modulation systems work&#46; The tests explore&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8211;</span><p id="par0065" class="elsevierStylePara elsevierViewall">Temporal summation &#40;wind up&#41;&#46; A repeated painful stimulus causes increased pain perception&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8211;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Conditioned pain modulation &#40;a distant pain stimulus reduces perception of the original pain&#41;&#46; This explores the integrity of the descending inhibitory pathway&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8211;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Central sensitization&#58; central sensitization is induced with a series of high-frequency electrical stimuli&#46; This usually subsides within 24<span class="elsevierStyleHsp" style=""></span>h&#44; but it can persist for several days or weeks in 20&#37; of the healthy population&#46;</p></li></ul></p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Material</span><p id="par0080" class="elsevierStylePara elsevierViewall">The minimum requirements for a basic QST lab are as follows&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Calibrated brush for the study of dynamic mechanical allodynia &#40;Brush-05&#174;&#44; Somedic SenseLab AB&#44; S&#246;sdala&#44; Sweden&#41;</span><p id="par0085" class="elsevierStylePara elsevierViewall">A calibrated brush or mini-brush consisting of a mixture of 20 natural and synthetic microfilaments measuring 20<span class="elsevierStyleHsp" style=""></span>mm in length&#59; the tip of the brush measures 15<span class="elsevierStyleHsp" style=""></span>mm across&#44; and each filament is 5<span class="elsevierStyleHsp" style=""></span>mm thick&#46; The average pressure of the brush against the skin is 100<span class="elsevierStyleHsp" style=""></span>mN &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">It can be replaced in practice by cotton wool or cotton buds &#40;Q-tips&#41;&#44; which must be used in continuous contact with the skin in an area measuring 1&#8211;2<span class="elsevierStyleHsp" style=""></span>cm&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Von Frey filaments</span><p id="par0095" class="elsevierStylePara elsevierViewall">A complete set of 20 plastic monofilaments numbered from 1&#46;65 to 6&#46;65 &#40;the logarithm 10 times the force in milligrams required to bow the monofilament&#41; for the Semmes&#8211;Weinstein monofilament test&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">6</span></a> The filament are applied perpendicularly&#44; and between 0&#46;0045 and 448<span class="elsevierStyleHsp" style=""></span>g of pressure are needed to bend the filament &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The filaments eventually lose consistency with use&#44; so they must be replaced periodically&#46; In some models only the filament needs to be replaced at a reasonable price&#44; not the holder&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Devices for the &#171;Pinprick&#187; test</span><p id="par0105" class="elsevierStylePara elsevierViewall">Ideally&#44; a set of 7 pinprick stimulators calibrated against their own weight should be used to administer sharp stimuli with an applied force of between 8 and 512<span class="elsevierStyleHsp" style=""></span>mN on a contact surface measuring 0&#46;2<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">2&#44;7</span></a> These instruments are very delicate and expensive&#44; and can easily lose calibration if used incorrectly&#46; They are used to measure mechanical pain thresholds and temporal summation &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">There is a very inexpensive and less accurate device &#40;it is not calibrated with its own weight&#44; but depends on the force applied by the clinician against a spring&#41; that applies a pressure of approximately 390<span class="elsevierStyleHsp" style=""></span>mN &#40;40<span class="elsevierStyleHsp" style=""></span>g&#41;&#44; which is usually the mean force needed to detect painful mechanical stimulation in most patients &#40;Neuropen&#174;&#44; Owen-Mumford Ltd&#46;&#44; Oxford&#44; Great Britain&#41;&#46; It also includes a 10<span class="elsevierStyleHsp" style=""></span>g monofilament for measuring mechanical sensitivity&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pressure algometry</span><p id="par0115" class="elsevierStylePara elsevierViewall">Many different algometers&#44; both analogue and digital&#44; are available&#46; Some have built-in data collection programmes and real-time graphics that improve the accuracy of the different tests applied by regulating the progressive application of pressure over time&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">They usually consist of a 1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> circular surface probe that can apply pressures of up to 200<span class="elsevierStyleHsp" style=""></span>N&#47;cm<span class="elsevierStyleSup">2</span> &#40;about 20<span class="elsevierStyleHsp" style=""></span>K&#47;cm<span class="elsevierStyleSup">2</span>&#41; with progressive ramp increments &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Thermal sensitivity evaluation devices or hot&#47;cold thermodes</span><p id="par0125" class="elsevierStylePara elsevierViewall">These are the most expensive instruments in the laboratory&#46; There are 2 types of thermodes&#58; those that can detect warm and cold perception thresholds&#44; as well as warm pain thresholds&#59; and more expensive models that can also study more complex cold pain thresholds&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">These devices consist of probes or thermodes of different sizes &#40;even for dental use&#41; which&#44; in contact with the skin&#44; apply ramp or progressive temperature stimuli that can range from 0&#176; C to 60<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; and usually start at 32<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; They can also administer discontinuous cold&#47;warm stimuli to measure discrimination&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">They operate on the basis of the Peltier thermoelectric effect by which a temperature difference is directly converted to electric voltage and vice versa&#46; This effect is also used in other fields to warm or cool objects&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">The devices currently available on the market are&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8211;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Modular Sensory Analyzer Thermal Stimulator&#174; &#40;Somedic SenseLab AB&#44; S&#246;sdala&#44; Sweden&#41;&#46; This is most comprehensive&#44; sophisticated and accurate device&#46; It is usually only used in universities or other academic facilities equipped with experimental laboratories&#46; It costs over &#8364;25&#44;000&#44; but curiously enough&#44; does not have a Food and Drug Administration seal for sale in the EU&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8211;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Medoc Q-sense&#174; &#40;Medoc Ltd&#44; Ramat Yishay&#44; Israel&#41;&#46; There are two models&#44; an inexpensive one that does not include detection of cold pain thresholds&#44; and a more sophisticated one that does&#46; Most are compatible with functional MRI studies&#46; The Q-sense&#174; can be connected to a computer for viewing data and generating clinical reports&#46; Prices start at &#8364;14&#44;000&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8211;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Thermal Cutaneous Stimulator-TCS&#174; &#40;QST&#46;Lab&#44; Strasbourg&#44; France&#41;&#46; This surprisingly simple&#44; intuitive&#44; portable device was launched less than a year ago&#46; It can be used for all kinds of studies&#44; and parameters can easily be customized&#59; however&#44; it does not yet have software adapted for clinical use&#46; The device costs around &#8364;17&#44;000&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8211;</span><p id="par0160" class="elsevierStylePara elsevierViewall">NerveCheck&#174; &#40;Phi Med Europe&#44; Barcelona&#44; Spain&#41;&#46; Developed in Spain to study diabetic neuropathy &#40;includes vibrometer&#41;&#44; this is the most inexpensive and easy-to-use of all such devices&#46; It does not include detection of cold pain thresholds&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">10</span></a> and is the only device to use the method levels instead of ramped stimulation&#46; Although this may be seen as a disadvantage&#44; many researchers believe it to be more reliable and precise because it eliminates the response time variable that varies greatly depending on age&#44; attention span&#44; etc&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a> It includes built-in software that plots the parameters on a graph&#44; currently costs less than &#8364;2000&#44; and it is a good option for start-up laboratories&#46; The only drawback is the cost of replacement sensors&#46;</p></li></ul></p><p id="par0165" class="elsevierStylePara elsevierViewall">Along with the aforementioned devices&#44; there is a simple instrument that can quickly detect anomalies in C and A-delta fibres over large body areas by discriminating between differences in temperature&#46; This is the Rolltemp II&#174; &#40;Somedic SenseLab AB&#44; S&#246;sdala&#44; Sweden&#41;&#44; which consists of 2 metal rollers measuring 15<span class="elsevierStyleHsp" style=""></span>mm across that are warmed in a special apparatus to 40<span class="elsevierStyleHsp" style=""></span>&#176;C &#40;red&#41; and 25<span class="elsevierStyleHsp" style=""></span>&#176;C &#40;blue&#41; &#8211; a difference of &#8722;7 and &#43;8<span class="elsevierStyleHsp" style=""></span>&#176;C from the normal average body temperature of 32<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; which is sufficient to detect normal and abnormal temperature sensitivity&#46; The device can be used to detect the level of subarachnoid or epidural anaesthesia in the operating room or the level of spinal damage in the emergency room &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Vibrometers</span><p id="par0170" class="elsevierStylePara elsevierViewall">These are used to evaluate vibration detection thresholds&#46; Most authors use calibrated tuning forks sets or a single adjustable frequency tuning fork &#40;Rydel-Seiffer scale&#44; 64<span class="elsevierStyleHsp" style=""></span>Hz&#44; 8&#47;8 scale&#41;&#44; which are very affordable&#46; Descending stimuli are applied to a bony surface &#40;styloid process on the wrist or malleolus on the foot&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The NerveCheck&#174; &#40;Phi Med Europe&#44; Barcelona&#44; Spain&#41; includes a digital vibrometer&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Although vibrometers are included in protocols&#44; their practical use in pain management is very limited and they are not usually included in clinical studies&#46; In patients with diabetic neuropathy&#44; however&#44; a higher vibration detection threshold has been associated with an exponential increase in complications related to ulcers and amputations&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Other devices</span><p id="par0185" class="elsevierStylePara elsevierViewall">Other devices can complement the information obtained and extend the scope of study&#44; for example&#44; by exploring the involvement of the sympathetic nervous system in pain&#46; In our laboratory&#44; for example&#44; we use computerized infrared thermal imaging &#40;FLIR Systems Inc&#46;&#44; Wilsonwille&#44; Oregon&#44; USA&#41; together with a laser-doppler tissue perfusion monitor &#40;Transonic Systems Inc&#46;&#44; Ithaca&#44; NY&#44; USA&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Some study protocols aimed at inducing central sensitization explore the response to different intensities of transcutaneous electrical nerve stimulation&#46; Many of the neurostimulators used by anaesthesiologists to explore neuromuscular relaxation and some of those used to locate peripheral nerves can be used for this purpose&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">The International Association for the Study of Pain 2013 consensus document</span><p id="par0195" class="elsevierStylePara elsevierViewall">QST studies must be performed systematically&#46; The variety of methodologies used by different groups involved in different lines of research can be confusing&#44; and many of them are impractical in clinical practice&#46; The consensus document published by the International Association for the Study of Pain &#40;IASP&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> based on the protocol developed by the German Neuropathic Pain Research Network&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a> is currently the best reference&#46; These are the basic recommendations&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8211;</span><p id="par0200" class="elsevierStylePara elsevierViewall">Test order&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">1&#46;</span><p id="par0205" class="elsevierStylePara elsevierViewall">From least to most painful&#58; mechanical detection thresholds-vibration threshold-temperature detection thresholds &#40;warm&#47;cold&#41;-temperature pain thresholds-mechanical pain thresholds-pressure pain thresholds&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">2&#46;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Observe wait-times between tests&#46; Dynamic studies or special protocols should be administered after a reasonable rest&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8211;</span><p id="par0215" class="elsevierStylePara elsevierViewall">They can either be performed using the method of limits&#44; where the stimulus is increased or decreased until a response is elicited from the patient &#40;verbal or pressing a button&#41;&#44; or using the method of levels&#44; which is not based on reaction time&#44; and is more time-consuming&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8211;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Null stimuli should be included &#40;although this is not mandatory&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8211;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Perform at least 3 determinations per patient for threshold detection&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8211;</span><p id="par0230" class="elsevierStylePara elsevierViewall">Area of application&#58;</p></li></ul><ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">1&#46;</span><p id="par0235" class="elsevierStylePara elsevierViewall">Peripheral polyneuropathy&#58; as distal as possible &#40;tip of the index finger&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">2&#46;</span><p id="par0240" class="elsevierStylePara elsevierViewall">Localized pain&#58; area of most pain and the contralateral area or&#44; where appropriate&#44; compare with another healthy area&#46; Always start with non-painful areas&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">3&#46;</span><p id="par0245" class="elsevierStylePara elsevierViewall">Generalized chronic pain &#40;variable&#44; depending on the purpose of the study&#41;&#46; One of the most widely used protocols is the evaluation of the bilateral trapezius and bilateral anterior tibial crest&#46;</p></li></ul><ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8211;</span><p id="par0250" class="elsevierStylePara elsevierViewall">Take the published normal reference values into account &#40;these vary greatly according to sex&#44; race&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a></p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8211;</span><p id="par0255" class="elsevierStylePara elsevierViewall">Duration&#58; 30&#8211;90<span class="elsevierStyleHsp" style=""></span>min&#44; depending on complexity&#46;</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study algorithm</span><p id="par0260" class="elsevierStylePara elsevierViewall">Despite these recommendations&#44; it is still difficult to adapt all this information to clinical practice&#46; In our group&#44; we use the following protocol based on IASP recommendations&#58;<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">1&#46;</span><p id="par0265" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mark the painful areas</span> indicated by the patient and choose the generalized or localized pain protocol&#46; Give the patient time to acclimitise&#44; explain the study to them and let them relax in a neutral&#44; quiet room&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">2&#46;</span><p id="par0270" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Dynamic mechanical allodynia</span> &#40;cotton wool&#47;Brush-05&#174;&#47;cotton swab&#41;&#46; Draw the outline of the areas of allodynia&#46; Determine allodynia yes&#47;no and the area&#46; Strictly speaking&#44; each area should be tested up to 5 times&#44; and if response is positive with the calibrated brush&#44; also try with the tip of a cotton swab&#44; which should apply a much lower pressure &#40;about 3<span class="elsevierStyleHsp" style=""></span>mN&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">7</span></a></p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">3&#46;</span><p id="par0275" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mechanical perception thresholds</span>&#46; Determine the level of mechanical perception in each area using von Frey filaments &#40;Semmes&#8211;Weinstein test&#41; in increasing and decreasing order&#46; The average value of 3&#8211;5 measurements is chosen&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">4&#46;</span><p id="par0280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Vibration thresholds&#46;</span> This is only used in diabetic or post-chemotherapy neuropathy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">5&#46;</span><p id="par0285" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cold&#47;warm detection thresholds</span>&#46; Increments and decrements from 32<span class="elsevierStyleHsp" style=""></span>&#176;C &#40;minimum 3<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; maximum 51&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; to 1<span class="elsevierStyleHsp" style=""></span>&#176;C&#47;s&#59; the method of limits can also be used&#46; The mean of 3 measurements is taken per area&#44; 30&#8211;90<span class="elsevierStyleHsp" style=""></span>min apart&#44; never on the same area&#44; but in close proximity to it&#46;</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">6&#46;</span><p id="par0290" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Mechanical perception thresholds</span>&#46; The expensive and delicate set of calibrated pinpricks should be replaced with medium to high thickness von Frey filaments that also reach 512<span class="elsevierStyleHsp" style=""></span>mN of maximum pressure &#40;pressure should vary between 8 and 512<span class="elsevierStyleHsp" style=""></span>mN&#41;&#46; The average of 3&#8211;5 series in ascending and descending order is taken&#46;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">7&#46;</span><p id="par0295" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pressure pain thresholds</span>&#46; We usually use the method of limits in this test&#46; Apply increments of 30&#8211;50<span class="elsevierStyleHsp" style=""></span>N&#47;m<span class="elsevierStyleSup">2</span> per second &#40;30<span class="elsevierStyleHsp" style=""></span>kPa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>N&#47;m<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>kg&#47;cm<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#46;4 pounds&#41;&#46; The mean of 3 measurements per area at 20<span class="elsevierStyleHsp" style=""></span>min intervals&#44; never in the same area but in close proximity to it&#44; is taken&#46; Apply a maximum pressure of 1000<span class="elsevierStyleHsp" style=""></span>N&#47;m<span class="elsevierStyleSup">2</span>&#44; and if no pain is elicited&#44; this is noted as a threshold of pain&#46;</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">8&#46;</span><p id="par0300" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cold&#47;hot pain thresholds</span>&#46; Only warm pain thresholds can be measured&#46; Increments and decrements from 32<span class="elsevierStyleHsp" style=""></span>&#176;C &#40;minimum 3<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; maximum 51&#46;5<span class="elsevierStyleHsp" style=""></span>&#176;C&#41; to 1<span class="elsevierStyleHsp" style=""></span>&#176;C&#47;s&#59; the method of limits can also be used&#46; The mean of 3 measurements is taken per area 30&#8211;90<span class="elsevierStyleHsp" style=""></span>min apart&#44; never on the same area&#44; but in close proximity to it&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">9&#46;</span><p id="par0305" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Conditioned pain modulation&#46;</span> Primarily used in chronic generalized pain or fibromyalgia to explore the descending inhibitory pathway&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> A remote area&#44; usually the arm or hand&#44; receives a painful stimulus &#40;ice cube<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> or ischaemia cuff&#44; maximum 10<span class="elsevierStyleHsp" style=""></span>min at 200<span class="elsevierStyleHsp" style=""></span>mmHg or up to VAS 6&#41;&#46; At the same time&#44; the pressure pain threshold test is repeated in the affected area&#46;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">10&#46;</span><p id="par0310" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Temporal summation &#40;wind up&#41;</span>&#46; A mechanical stimulus &#40;pinprick or filament&#41; above the pain threshold &#40;almost always around 256<span class="elsevierStyleHsp" style=""></span>mN or higher&#41; is chosen&#46; The stimulus is applied once and the patient is asked to rate it from 1 to 10 &#40;or 1&#8211;100&#41;&#46; After 10 stimuli applied at regular intervals &#40;1 stimulus<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>second&#44; or even using a metronome&#41; on the same localized 1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span> area&#44; ask the patient to rate the last stimulus&#46; Under normal conditions&#44; this will be at least 20&#37; higher than the baseline measurement&#46; The difference between the last score and the baseline value is the <span class="elsevierStyleItalic">wind</span>-<span class="elsevierStyleItalic">up</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a></p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">11&#46;</span><p id="par0315" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Central sensitization induction</span>&#46; With a neurostimulator located in the forearm&#44; the threshold of a high frequency electrical stimulus &#40;100<span class="elsevierStyleHsp" style=""></span>Hz&#41; is first determined by increasing and decreasing the stimulus &#40;average of 3&#8211;5 measurements&#41;&#46; Next&#44; stimuli of the same frequency but 10 times the intensity of the detection threshold are applied 5 times for 1<span class="elsevierStyleHsp" style=""></span>s &#40;pulses of 2<span class="elsevierStyleHsp" style=""></span>ms with 10<span class="elsevierStyleHsp" style=""></span>s intervals between each stimulus&#41;&#46; After 10<span class="elsevierStyleHsp" style=""></span>min&#44; the threshold tests for mechanical pain and for electrical stimulation are started and repeated at 2&#44; 4&#44; 8&#44; 24&#44; 48 and 72<span class="elsevierStyleHsp" style=""></span>h&#46; A significant decrease in pain thresholds will be observed due to the appearance of central sensitization mediated by the mechanism known as long-term enhancement of pain perception after short&#44; high-frequency stimuli applied to the posterior medullary horn&#46; This phenomenon usually subsides after 24<span class="elsevierStyleHsp" style=""></span>h&#44; but in predisposed individuals it can last for days&#44; and puts them at greater risk of developing symptoms such as chronic postoperative pain&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">12&#46;</span><p id="par0320" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Supra-threshold stimuli and pain tolerance thresholds or pain withdrawal reflex</span>&#46; These are rarely used&#44; except in experimental studies&#46; They require specific consent and must be performed outside the context of routine studies&#46; The technique involves applying stimuli&#44; generally pressure&#44; temperature or electrical&#44; above the pain threshold to assess hyperalgesia&#44; and even up to the limit of the patient&#39;s tolerance in the case of withdrawal reflex&#46;</p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Specific study design</span><p id="par0325" class="elsevierStylePara elsevierViewall">A vast array of methodologies are available for particular disease&#46; To simplify&#44; we propose the following battery of tests for the most frequent cases&#44; taking into account the recommendations of the IASP&#46;<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">1&#46;</span><p id="par0330" class="elsevierStylePara elsevierViewall">Generalized chronic pain&#46;<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">&#8211;</span><p id="par0335" class="elsevierStylePara elsevierViewall">Area&#58; bilateral trapezium &#40;10<span class="elsevierStyleHsp" style=""></span>cm from acromion&#41; and anterior tibial &#40;10<span class="elsevierStyleHsp" style=""></span>cm from lower border of patella&#41;&#46; Requires a pain-free control area&#46;</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">&#8211;</span><p id="par0340" class="elsevierStylePara elsevierViewall">Test&#58; mechanical &#40;allodynia&#44; perception and pain thresholds&#41;&#44; pressure &#40;pain threshold&#41;&#44; temperature &#40;cold&#47;warm and warm pain perception thresholds&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">&#8211;</span><p id="par0345" class="elsevierStylePara elsevierViewall">Conditioned pain modulation&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">2&#46;</span><p id="par0350" class="elsevierStylePara elsevierViewall">Localized pain&#46;<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">&#8211;</span><p id="par0355" class="elsevierStylePara elsevierViewall">Mark the area of pain and contralateral area&#46;</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">&#8211;</span><p id="par0360" class="elsevierStylePara elsevierViewall">Test&#58; mechanical &#40;allodynia&#44; perception and pain thresholds&#41;&#44; pressure &#40;pain threshold&#41;&#44; temperature &#40;cold&#47;warm and warm pain perception thresholds&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">&#8211;</span><p id="par0365" class="elsevierStylePara elsevierViewall">Temporary summation&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">3&#46;</span><p id="par0370" class="elsevierStylePara elsevierViewall">Perineal pain&#46;<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">&#8211;</span><p id="par0375" class="elsevierStylePara elsevierViewall">Mark the area of pain and contralateral area&#46; If bilateral&#44; compare with trapezoids&#46;</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">&#8211;</span><p id="par0380" class="elsevierStylePara elsevierViewall">Test&#58; mechanical &#40;allodynia&#44; perception and pain thresholds&#41;&#44; pressure &#40;pain threshold&#41;&#44; temperature &#40;cold&#47;warm and warm pain perception thresholds&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">&#8211;</span><p id="par0385" class="elsevierStylePara elsevierViewall">Temporary summation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">&#8211;</span><p id="par0390" class="elsevierStylePara elsevierViewall">Conditioned pain modulation in vulvodynia&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">4&#46;</span><p id="par0395" class="elsevierStylePara elsevierViewall">Headache&#46; In migraines&#44; test the frontal&#44; temporal and occipital &#40;midline between mastoids and inion&#41; and contralateral areas&#46; In case of holocranial headache&#44; compare with tibial crest or trapezius &#40;if no pain is reported at that level&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a><ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">&#8211;</span><p id="par0400" class="elsevierStylePara elsevierViewall">Test&#58; mechanical &#40;allodynia&#44; perception and pain thresholds&#41;&#44; pressure &#40;pain threshold&#41;&#44; temperature &#40;cold&#47;warm and warm pain perception thresholds&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">&#8211;</span><p id="par0405" class="elsevierStylePara elsevierViewall">Temporary summation&#46;</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">&#8211;</span><p id="par0410" class="elsevierStylePara elsevierViewall">Conditioned pain modulation&#46;</p></li></ul></p></li></ul></p><p id="par0415" class="elsevierStylePara elsevierViewall">Sympathetic response in the palmar region can be tested in each case using a laser-Doppler probe and computerized infrared thermography to measure microcirculation&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Predictive value of QST studies</span><p id="par0420" class="elsevierStylePara elsevierViewall">Although there are no universal rules&#44; certain data from QST studies are associated with certain pathophysiological mechanisms&#44; clinical diagnoses&#44; risk of complications&#44; or response to certain treatments&#46; They cannot be used to achieve a firm diagnosis&#44; but can give an orientation&#46;<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">a&#46;</span><p id="par0425" class="elsevierStylePara elsevierViewall">Risk of developing chronic pain<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">18</span></a>&#58;<ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">&#8211;</span><p id="par0430" class="elsevierStylePara elsevierViewall">Alteration of conditioned pain modulation &#40;generalized chronic pain&#44; fibromyalgia&#44; etc&#46;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">&#8211;</span><p id="par0435" class="elsevierStylePara elsevierViewall">Delayed recovery after central sensitization &#40;chronic post-operative pain&#41;&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">b&#46;</span><p id="par0440" class="elsevierStylePara elsevierViewall">Efficacy of pharmacological treatments<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">18&#44;19</span></a>&#58;<ul class="elsevierStyleList" id="lis0085"><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">&#8211;</span><p id="par0445" class="elsevierStylePara elsevierViewall">Low pressure pain threshold and moderate allodynia &#40;capsaicin&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a></p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">&#8211;</span><p id="par0450" class="elsevierStylePara elsevierViewall">Pinprick test positive for mechanical hyperalgesia &#40;pregabalin&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">&#8211;</span><p id="par0455" class="elsevierStylePara elsevierViewall">Hyperalgesia with preserved sensory functions &#40;irritable nociceptor syndrome&#41; &#40;oxcarbazepine&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">&#8211;</span><p id="par0460" class="elsevierStylePara elsevierViewall">Alteration of conditioned pain modulation &#40;duloxetine&#41;&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">c&#46;</span><p id="par0465" class="elsevierStylePara elsevierViewall">Mechanisms involved<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a>&#58;<ul class="elsevierStyleList" id="lis0090"><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">&#8211;</span><p id="par0470" class="elsevierStylePara elsevierViewall">Low mechanical and thermal sensory perception &#40;deafferentation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0320"><span class="elsevierStyleLabel">&#8211;</span><p id="par0475" class="elsevierStylePara elsevierViewall">Thermal hyperalgesia&#44; no sensory alteration &#40;peripheral sensitization&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0325"><span class="elsevierStyleLabel">&#8211;</span><p id="par0480" class="elsevierStylePara elsevierViewall">Mechanical hyperalgesia&#44; slight decrease in thermal sensitivity&#44; facilitated temporal summation &#40;central sensitization&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a></p></li></ul></p></li></ul></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion and conclusions</span><p id="par0485" class="elsevierStylePara elsevierViewall">QST studies give clinicians a more accurate and objective approach to nociceptive pain&#46; The knowledge gained through basic laboratory research has now been translated into clinical practice in many of our neighbouring countries&#46;</p><p id="par0490" class="elsevierStylePara elsevierViewall">Despite IASP recommendations&#44; the proliferation of methodologies and variants in the literature can be confusing to clinicians entering this field for the first time&#46;</p><p id="par0495" class="elsevierStylePara elsevierViewall">Mastering QST requires many hours of study&#44; training and practice in order to fully understand the different techniques and adapt them to our clinical practice&#46; However&#44; once the methodology of each test has been well defined&#44; they can be simply and routinely applied&#46; Therefore&#44; a good strategy would be to start with simple devices such as von Frey filaments or pressure algometers&#44; and once familiarized with these&#44; start incorporating allodynia records&#44; perception thresholds&#44; and mechanical and pressure pain perception in clinical studies of acute or chronic pain&#44; along with standard pain scales &#40;VAS&#44; Brief Pain Inventory&#44; etc&#46;&#41;&#46; In patients with neuropathic pain&#44; QST studies have shown better correlation with the severity of neuropathy than different disease-specific scales&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">23</span></a> It would be advisable to include these tests in the training curriculum of anaesthesiology and critical care residents&#46;</p><p id="par0500" class="elsevierStylePara elsevierViewall">The most comprehensive and complex QST studies should be included in the services offered by highly specialized Pain Units&#44; and can be used for at least three purposes&#58;<ul class="elsevierStyleList" id="lis0095"><li class="elsevierStyleListItem" id="lsti0330"><span class="elsevierStyleLabel">a&#46;</span><p id="par0505" class="elsevierStylePara elsevierViewall">In clinical trials designed to evaluate the effectiveness of new drugs or therapies&#46;</p></li><li class="elsevierStyleListItem" id="lsti0335"><span class="elsevierStyleLabel">b&#46;</span><p id="par0510" class="elsevierStylePara elsevierViewall">To improve our understanding of the pathophysiological mechanisms of complex pain&#46;</p></li><li class="elsevierStyleListItem" id="lsti0340"><span class="elsevierStyleLabel">c&#46;</span><p id="par0515" class="elsevierStylePara elsevierViewall">To draw up reports of patients with primary chronic pain that can be used in forensic medicine&#46; The growing prevalence of primary chronic pain was highlighted in the latest International Classification of Diseases &#40;ICD-11&#41; proposed by the IASP and published by the World Health Organization &#40;WHO&#41; in 2019&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">24</span></a></p></li></ul></p></span></span>"
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          "identificador" => "sec0005"
          "titulo" => "Introduction"
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          "titulo" => "Classification"
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          "titulo" => "Material"
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              "titulo" => "Calibrated brush for the study of dynamic mechanical allodynia &#40;Brush-05&#174;&#44; Somedic SenseLab AB&#44; S&#246;sdala&#44; Sweden&#41;"
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            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Von Frey filaments"
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              "identificador" => "sec0030"
              "titulo" => "Devices for the &#171;Pinprick&#187; test"
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            3 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Pressure algometry"
            ]
            4 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Thermal sensitivity evaluation devices or hot&#47;cold thermodes"
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            5 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Vibrometers"
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            6 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Other devices"
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        7 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "The International Association for the Study of Pain 2013 consensus document"
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          "identificador" => "sec0060"
          "titulo" => "Study algorithm"
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        9 => array:2 [
          "identificador" => "sec0065"
          "titulo" => "Specific study design"
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          "identificador" => "sec0070"
          "titulo" => "Predictive value of QST studies"
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            0 => "Pain"
            1 => "Quantitative sensory testing"
            2 => "Neuropathic pain"
            3 => "Pain assessment"
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          "palabras" => array:4 [
            0 => "Dolor"
            1 => "Estudio sensitivo cuantitativo"
            2 => "Dolor neurop&#225;tico"
            3 => "Evaluaci&#243;n del dolor"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Quantitative sensory testing &#40;QST&#41; is used to globally analyze the nociceptive system in order to obtain a more objective understanding of pain perception&#46; In recent years&#44; QST has become a common tool in many pain clinics and anesthesiology departments worldwide&#46; In 2013&#44; the Neuropathic Pain Special Interest Group of the IASP put forward the first recommendations for conducting QST in clinical practice and research&#46; However&#44; the wide variety of QST methodologies and standards in the literature make it difficult to generalize the used of this tool in clinical practice&#46; In this study&#44; we present the basic concepts of QST&#44; the type of tests and devices used&#44; how they are applied&#44; and the role of QST in anesthesiology and pain management&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Los estudios sensitivos cuantitativos&#44; m&#225;s conocidos por sus siglas en ingl&#233;s QST &#40;Quantitative Sensory Testing&#41;&#44; son un conjunto de pruebas que permiten evaluar de forma integral el sistema nociceptivo y obtener informaci&#243;n m&#225;s objetiva de c&#243;mo se percibe el dolor&#46; En los &#250;ltimos a&#241;os se ha convertido en una herramienta de uso com&#250;n en muchas Unidades del Dolor y Departamentos de Anestesiolog&#237;a de muchos pa&#237;ses&#46; En 2013&#44; el Grupo de Dolor Neurop&#225;tico de la IASP propuso las primeras recomendaciones para su aplicaci&#243;n en la pr&#225;ctica cl&#237;nica y en investigaci&#243;n&#46; No obstante&#44; existen multitud de variantes metodol&#243;gicas publicadas&#44; con est&#225;ndares no armonizados&#44; que hacen que resulte complejo introducirse en este campo y generalizar su uso&#46; En este trabajo intentamos presentar los fundamentos&#44; tipos de test y dispositivos&#44; metodolog&#237;a de aplicaci&#243;n y su utilidad en Anestesiolog&#237;a y Tratamiento del Dolor&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Avellanal M&#44; Riquelme I&#44; D&#237;az-Rega&#241;&#243;n G&#46; Test sensitivos cuantitativos &#40;&#171;Quantitative Sensory Testing&#187;&#41; en el diagn&#243;stico y tratamiento del dolor&#46; Breve revisi&#243;n y propuesta de protocolizaci&#243;n de empleo&#46; Rev Esp Anestesiol Reanim&#46; 2020&#59;67&#58;187&#8211;194&#46;</p>"
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            0 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "1"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Psychophysical scaling&#58; an overview"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "G&#46; Borg"
                          ]
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                    0 => array:1 [
                      "LibroEditado" => array:5 [
                        "paginaInicial" => "27"
                        "paginaFinal" => "39"
                        "serieVolumen" => "vol&#46; 3"
                        "serieTitulo" => "Touch&#44; temperature&#44; and pain in health and disease&#58; mechanisms and assessments&#46; Progress in pain research and management"
                        "serieFecha" => "1994"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Quantitative sensory testing&#58; a comprehensive protocol for clinical trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; Rolke"
                            1 => "W&#46; Magerl"
                            2 => "K&#46; Andrews Campbell"
                            3 => "C&#46; Schalber"
                            4 => "S&#46; Caspari"
                            5 => "F&#46; Birklein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ejpain.2005.02.003"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Pain"
                        "fecha" => "2006"
                        "volumen" => "10"
                        "paginaInicial" => "77"
                        "paginaFinal" => "88"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16291301"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
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