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Quantitative Sensory Tests (QST)

Quantitative Sensory Tests (QST). Sensory Test Modality Studied Fibers Studied. Von-Frey hairs, Mechanical Large and small myelinated algometer and unmyelinated axons Thermotest Temperature Small myelinated and unmyelinated sensory axons Vibrameter Vibration Large myelinated sensory

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Quantitative Sensory Tests (QST)

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  1. Quantitative Sensory Tests(QST) SensoryTest Modality Studied Fibers Studied Von-Frey hairs, Mechanical Large and small myelinated algometer and unmyelinated axons Thermotest Temperature Small myelinated and unmyelinated sensory axons Vibrameter Vibration Large myelinated sensory axons Dotson RM et al. J Clin Neurophysiol. 1997;14:32-45; Olney RK. J Clin Neurophysiol. 1998;15:129-137.

  2. Cotton Swab andVon Frey Hair Photo courtesy of Baron.

  3. Histamine Test Thermography Photo courtesy of Baron (left). Photo courtesy of Fields (right)

  4. Skin-Punch Biopsy (皮膚切片檢查) Intraepidermal nerve fiber density Reduced density in sensoryneuropathy with abnormalnerve fiber swelling Normal density Arezzo JC. Am J Med. 1999;107:9S-16S.

  5. Thalamic stroke(Central Post-Stroke Pain) R Photo courtesy of Tölle.

  6. 疼痛影響大腦的範圍,可能超出我們的想像!

  7. 疼痛治療的目標提升生活品質減少疼痛指數治癒減緩病程疼痛治療的目標提升生活品質減少疼痛指數治癒減緩病程 • 非藥物 • 藥物

  8. 非藥物治療準則及選項

  9. 藥物治療原則Short Reminding • 不同疾病的疼痛,所使用的藥物不盡相同 • 量身訂做(Tailor for individual). • 腸胃系統的疼痛,使用NSAID可能會加重病情. • 嗎啡類藥物不可用於初始治療. • 盲目的結合給藥,可能造成藥物交互作用或副作用. • EBM可作為臨床治療指引.(定期修正)

  10. 範例:EFNS guideline (2010)-歐洲聯盟準則

  11. 範例: Recommendation for DPNP treatment (AAN 2011)

  12. Anti-epileptic drugs (AEDs):神經穩定劑 (抗癲癇用藥) • Common link among all anticonvulsants is their ability to modulate neurotransmission: • Limit sustained repetitive firing by modulating Na+ channels.(Dilantin, Tegretrol, Mexitiline) • Inhibit the influx of calcium through Voltage-gated Ca2+ channels..(Neurontin, Pregabalin) • Enhance GABA-mediated inhibition.(Baclofen) • Reduce glutamate-mediated excitation.(BZD-valium) GABA = -aminobutyric acid.

  13. Diplopia Sedation Hyponatremia Nausea/Vomiting Ataxia Dizzy Somnolence Thrombocytopenia Hair loss Rash Pancreatitis Tremor 副作用 of Anticonvulsants(需要逐漸調整藥物)

  14. 史蒂芬-強生症候群(Stevens-Johnson syndrome) • HLA-B*1502 (sensitivity 100%, specificity 97%)-Tegretol, Dilantin

  15. Commonly reported AEs: Blurred vision Cognitive changes Constipation Dry mouth Orthostatic hypotension Sedation Sexual dysfunction Tachycardia Urinary retention QT prolongation Desipramine Nortriptyline Imipramine Doxepine Amitriptyline TCAs: 三環抗鬱劑Adverse Effects FewestAEs Most AEs

  16. SNRI-(serotonin, non-epinephrine reuptake inhibition) • Safety and effective in major depression and DPNP. • Less and few ADE than TCA. • Effective fast than SSRI and TCA (or tetracyclic~ludiomil) • Contraindication- MAOI, narrow-angled glaucoma. • Be aware of use in younger adults or teen age.

  17. 疼痛的精神心理機轉 Spino-thalamic tract 感受/認知疼痛 杏仁核 (恐懼中樞) 海馬迴 (記憶中樞) 恐懼擔憂疼痛 Spino-limbic tract

  18. TAKE HOME MESSAGE • 疼痛每人感受不同,以VAS(1-100)分類,先暸解疼痛嚴重度. • 區分為神經痛或組織發炎性疼痛; 急性或慢性. • 量身訂做(Individual tailor),個人不同, 給與適當治療. • 依據WHO給藥標準(麻藥應該放在2線) • 教育(Educate)病患疼痛之緩解必須一段時間,不可操之過 • 適當的日記記錄(Diary),有助於了解病情進展. • 醫師精準用藥(單一或多重)/復健/電刺激/針灸…

  19. 請自由發問~

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