symptoms, signs, and underlying mechanisms …symptoms, signs, and underlying mechanisms ... painful...
TRANSCRIPT
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Phenotyping Chronic Pain Patients
SYMPTOMS, SIGNS, AND UNDERLYING MECHANISMS
Clifford Woolf
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Disease
Age
Gender
Symptoms – amplitude, distribution and quality
Signs
Psychosocial factors
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No PainMildModerateSevere
Stimulus – response relationship
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Rheumatoid arthritis Osteoarthritis Postoperative Pain Post-traumatic Pain Painful peripheral diabetic neuropathy Postherpetic neuralgia HIV neuropathyAxial low back pain Lumbar radiculopathy Spinal Stenosis SpondylolisthesisFibromyalgia Interstitial Cystitis Irritable Bowel Disease Non cardiac chest painMigraine Tension type headache Cluster headache Trigeminal neuralgia Angina Claudication Vulvodynia Cancer Pain Atypical facial painRheumatoid arthritis Osteoarthritis Postoperative Pain Post-traumatic Pain Painful peripheral diabetic neuropathy Postherpetic neuralgia HIV neuropathyAxial low back pain Lumbar radiculopathy Spinal Stenosis SpondylolisthesisFibromyalgia Interstitial Cystitis Irritable Bowel Disease Non cardiac chest painMigraine Tension type headache Cluster headache Trigeminal neuralgia Angina Claudication Vulvodynia Cancer Pain Atypical facial painRheumatoid arthritis Osteoarthritis Postoperative Pain Post-traumatic Pain Painful peripheral diabetic neuropathy Postherpetic neuralgia HIV neuropathyAxial low back pain Lumbar radiculopathy Spinal Stenosis SpondylolisthesisFibromyalgia Interstitial Cystitis Irritable Bowel Disease Non cardiac chest painMigraine Tension type headache Cluster headache Trigeminal neuralgia Angina Claudication Vulvodynia Cancer Pain Atypical facial pain
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• Nociception
• Peripheral sensitization
• Ectopic excitability
• Phenotypic switch
• Central sensitization
• Altered circuitry
• Disinhibition
• Increased facilitation
• Neuroimmune interactions
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Peripheral sensitization
Heat allodynia
Ectopic excitability in nociceptors
Spontaneous pain
Central sensitization
Dynamic tactile allodynia
Secondary hyperalgesia
Neurobiological mechanisms & Pain Phenotype
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History - SymptomsPhysical examination - Signs
Quantitative sensory testsClinical ElectrophysiologyImaging
Genotype
Measuring Pain Phenotype
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April 2009
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Standardized Interview
Current pain state
Pain location
Onset and time course
Temporal characteristics
Pain-evoking stimuli
Quality of the pain
Effect of drug therapy and other pain-alleviating conditions
Non-painful sensations
Sensory deficits
Physical examination
Skin and appendages, subcutaneous tissue
Skin lesions
Swelling
Change of skin color
Altered sweating
Trophic changes
Pressure sensitivity of deep tissues
Sensory nervous system
Response to punctuate mechanical stimuli
Sense of vibration
Response to thermal stimuli
Temporal summation
Sense of position and response to movement
Response to pressure
Response to a dynamic mechanical stimulus
Pinprick pain
Pain Phenotype
Each individual has 85 tags defining their pain “universe”
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Enrollment
Postherpetic neuralgia 23 Painful diabetic polyneuropathy 50 Low back pain with signs of nerve root damage rLBP 57 Axial low back pain w/o radicular symptoms or signs aLBP 57
Total 187
Inclusion criteria:
At least 18 years of age Chronic pain ( 3 months) Average pain intensity rated 6/10 or higher on a numerical rating scale
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Standardized interview 46 items
0 187
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Physical examination 39 items
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Combined history and examination
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aLBP
PHN
rLBP
PDN
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Unbiased Screen
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aLBPrLBP
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Classification Tree Analysis
StEP = 6 interview & 10 examination items
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Trial 2 to test if StEP can distinguish aLBP from rLBP
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Douleur Neuropathique
StEP
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Peripheral sensitization
Central sensitization
Ectopic activity
Disinhibition
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Diagnosis: aLBP vs rLBP
Identify responders to different treatments?
Measure treatment response – change in phenotype?
Identify risk of chronicity?
“Pain Phenotype” Patients
PubMed 2011 2 hits
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Joachim Scholz Richard Mannion