Pain-Orientated Sensory Testing (POST) Guidelines

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Marvin Copeland
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1 PM Faculty f Pain Medicine Australian and New Zealand Cllege f Anaesthetists Pain-Orientated Sensry Testing (POST) Guidelines PREAMBLE These guidelines utline standardised terminlgy, equipment and techniques fr Pain- Orientated Sensry Testing (POST) in clinical practice and examinatins, fr Fellws and Trainees f the Faculty f Pain Medicine, Australian and New Zealand Cllege f Anaesthetists (FPM). Because a wide variety f sensry testing techniques are used in clinical practice, the Faculty develped these guidelines t facilitate a cnsistent and practical bedside apprach t POST, particularly fr trainees presenting fr FPM examinatins. POST is based n publicatins listed in the bibligraphy including the Faculty s Pain Oriented Physical Examinatin (POPE) guidelines. 1-7 STANDARD EQUIPMENT Camel hair brush (1 cm brush width) Cttn wl balls Ccktail sticks (tthpicks) (wden) 128 Hz stainless steel tuning frk ( large size with flat base plate) Tendn hammer (larger size) Timer Alchl wipes (disinfectin f camel hair brush between patients) OPTIONAL EQUIPMENT Neurtips (hyperalgesia testing) Water bath & C-size batteries (warmth alldynia testing) Hand-held infrared thermmeter (skin r water bath temperature testing) 50 mm paper clips (2-pint discriminatin testing) Tape measure (mm markings) PRINCIPLES OF SENSORY TESTING (Cmpare sides & sites) Cmpare sides: cmpare sensatin n ppsite sides (mirrr testing). Cmpare sites: cmpare sensatin at test site with a nrmal (reference) site. INFECTION CONTROL DO NOT apply r test any equipment n yur wn skin prir t using it n the patient, particularly sharps such as Neurtips r ccktail sticks.

2 ROUTINE TECHNIQUES ALLODYNIA Pain due t a (nn-nxius) stimulus that des nt nrmally prvke pain. 3 is a clinical feature frm which central might be inferred. Dynamic Mechanical (brush-evked) Tangentially strke the skin with a camel hair brush OR a cttn wl ball Apply a 2 cm lng brush-strke ver 1 secnd* and repeat *Cunting ne thusand-and-ne = 1 secnd Punctate Mechanical Stimulate the skin with a ccktail stick (tthpick) Apply 2 stimuli per secnd* (2 Hz) and repeat II II II II Pressure-evked Mechanical Apply pressure t sft tissues with tip f yur index finger until the nail bed blanches Apply the stimulus fr 1 secnd* and repeat Cld Apply the cld prngs f a stainless steel tuning frk t the skin Apply the stimulus fr 1 secnd* and repeat Stainless steel frk acts as a heat sink at rm temperature (± 20 C) (mimics nn-nxius cld) POST guidelines 2018 V2.0 Page 2 f 6

3 HYPERPATHIA (tempral summatin) An abnrmally painful reactin t a repetitive (cutaneus) stimulus. 3 Smetimes called tempral summatin. Hyperpathia is a clinical test fr the presence f central. Hyperpathia is the clinical test that demnstrates wind-up. Hyperpathia (tempral summatin) Stimulate the skin with a ccktail stick (tthpick) Apply 2 stimuli per secnd* (2Hz) and repeat Ask a baseline pain scre during this stimulatin Then cntinuusly stimulate skin at 2 stimuli per secnd (2Hz) fr 30 secnds (timer) Ask a final pain scre immediately after last stimulus (30 secnd mark) Increased final pain scre cmpared with baseline = hyperpathia Ask if pain cntinues after stimulatin ceases (after-sensatins) II II II (baseline pain scre) II 30 sec II (final pain scre) OPTIONAL TECHNIQUES The fllwing ptinal POST techniques DO NOT need t be perfrmed rutinely. Optinal techniques may be used when clinically indicated, r in pain research. HYPERALGESIA An increased pain respnse t a (nxius) stimulus that nrmally prvkes pain. 3 By definitin, must deliberately apply a ptentially nxius t test fr hyperalgesia. A ptentially nxius. pinprick stimulus is applied using a Neurtips needle. Hyperalgesia is a clinical test fr the presence f central. Punctate mechanical alldynia testing is a suitable alternative t hyperalgesia testing. Hyperalgesia (ptinal) Stimulate the skin with a Neurtips needle Apply 2 stimuli per secnd* (2Hz) and repeat II II II II POST guidelines 2018 V2.0 Page 3 f 6

4 Warm (ptinal) Warm a C-size battery in water bath at 45 C fr 5 minutes (use IR thermmeter) Then apply base f the battery t the skin Apply the stimulus fr 1 secnd* and repeat Battery acts as a heat surce at 45 C (nn-nxius warmth) INFRARED THERMOMETRY A hand-held infrared thermmeter is used t measure skin temperature in an area where altered sensry, sympathetic nervus system r vascular functin is suspected (e.g. cmplex reginal pain syndrme, painful diabetic neurpathy). Cmpare temperatures n ppsite sides (mirrr measurements). A temperature difference f 1.0 C between sides is cnsidered significant. 6 Infrared Thermmetry (ptinal) Direct a hand-help infrared thermmeter t an area f skin Cmpare skin temperature with the ppsite side (mirrr measurement) BIBLIOGRAPHY 1. Cruccu G, Smmer C, Anand P, et al. EFNS guidelines n neurpathic pain assessment: revised Eur J Neurl 2010;17(8): Haanpaa M, Rwbtham M. Diagnsing Neurpathic Pain: Clinical Examinatin, Neurphysilgy and Neurimaging. Pain Refresher Curse, 14th Wrld Cngress n Pain. Tracey I. (Ed). IASP Press, Seattle Internatinal Assciatin fr the Study f Pain. IASP Taxnmy. default.htm (accessed 2 Octber 2011). 4. Maier C, Barn R, Tölle TR, et al. Quantitative sensry testing in the German Research Netwrk n Neurpathic Pain (DFNS): Smatsensry abnrmalities in 1236 patients with different neurpathic pain syndrmes. Pain 2010;150(3): Pain Oriented Physical Examinatin (POPE). Chen M. (Ed); FPMANZCA, Melburne Australia, 2003 (DVD). 6. Schilder JC, Niehf SP, Marinus J, van Hilten JJ. Diurnal and ncturnal skin temperature regulatin in chrnic cmplex reginal pain syndrme. J Pain. 2015;16(3): Walk D, Sehgal N, Meller-Bertram T, et al. Quantitative sensry testing and mapping: a review f nnautmated quantitative methds fr examinatin f the patient with neurpathic pain. Clin J Pain 2009;25(7): POST guidelines 2018 V2.0 Page 4 f 6

APPENDIX 1: POST definitins, equipment and clinical techniques Terminlgy Equipment Technique Transmissin Inference Dynamic Mechanical (Brush-evked) Camel hair brush OR Cttn wl ball Tangentially strke

5 APPENDIX 1: POST definitins, equipment and clinical techniques Terminlgy Equipment Technique Transmissin Inference Dynamic Mechanical (Brush-evked) Camel hair brush OR Cttn wl ball Tangentially strke the skin Apply a 2 cm brush strke ver 1 sec & repeat Aβ Punctate Mechanical Wden ccktail stick (tthpick) Stimulate the skin using a ccktail stick Apply punctate stimulus; 2 x per sec (2Hz) & repeat Pressureevked Mechanical Index finger Press sft tissues with tip f index finger until nail bed blanches Apply pressure stimulus fr 1 sec & repeat Cld 128 Hz steel tuning frk Apply steel prngs f a tuning frk t the skin Apply cld stimulus fr 1 sec & repeat Hyperpathia Tempral Summatin Wden ccktail stick (tthpick) Repeatedly apply punctate stimulus t skin; 2 x per sec (2Hz) fr 30 sec Change in pain scre? Aftersensatins? Clinical test fr wind-up Hyperalgesia (Optinal) Neurtips needle Stimulate the skin using a Neurtips needle Apply sharp, (painful) stimulus; 2 x per sec (2Hz) & repeat POST guidelines 2018 V2.0 Page 5 f 6

Terminlgy Equipment Technique Transmissin Inference Warmth (Optinal) C-sized battery, warm water bath (baby-bttle warmer), IR thermmeter, stpwatch Warm battery in water bath at 45 C fr 5 minutes;

C Pint IR thermmeter at skin Cmpare temperature t ppsite side ΔT 1.

steel tuning frk aβ fibre drsal Intact aβ fibre & drsal functin Deep Tendn Reflexes Tendn hammer I a & II sensry afferents α mtr neurn Mtr reflex arc Threshlds: Tw-pint Discriminatin 50 mm paper clip

6 Terminlgy Equipment Technique Transmissin Inference Warmth (Optinal) C-sized battery, warm water bath (baby-bttle warmer), IR thermmeter, stpwatch Warm battery in water bath at 45 C fr 5 minutes; apply base f battery t the skin Apply heat stimulus fr 1 sec & repeat C fibre Peripheral Infrared Thermmetry (Optinal) Held-held infrared (IR) thermmeter Measures physilgical temperature range: C Pint IR thermmeter at skin Cmpare temperature t ppsite side ΔT 1.0 C = significant Altered sympathetic and/r vascular functin Tuch Sensatin Cttn wl Tuch the skin using a single dabbing mtin aβ fibre drsal Intact aβ fibre & drsal functin Vibratin Sensatin 128 Hz steel tuning frk aβ fibre drsal Intact aβ fibre & drsal functin Deep Tendn Reflexes Tendn hammer I a & II sensry afferents α mtr neurn Mtr reflex arc Threshlds: Tw-pint Discriminatin 50 mm paper clip bent int shape millimetre ruler r tape finger: 5 mm palm: 10 mm sle: 10 mm face: 15 mm limb: 40 mm back: 40 mm trs: 40 mm Apply 2-pint stimulus fr 1 sec, then repeat aβ fibre drsal Intact aβ fibre & drsal functin Reduced discriminatin due t altered CNS prcessing Prmulgated: 2013 Date f current dcument (V2.0): April 2018 This dcument is Cpyright and cannt be reprduced in whle r in part withut prir permissin. POST guidelines 2018 V2.0 Page 6 f 6

Year 2 MBChB Clinical Skills Session Examination of the Sensory System

Year 2 MBChB Clinical Skills Sessin Examinatin f the Sensry System Reviewed & ratified by: Dr D Smith Cnsultant Neurlgist Dr R Davies Cnsultant Neurlgist Dr B Michael Neurlgy Clinical Lecturer Dr J Williamsn