The Clinical approach

- In outpatient practice it is important to make a first essential screening (neuropathic, nociceptive, mixed pain).

The aim of this section of the Scientific Programme is to give a quick reference flow chart for clinicians mainly working in outpatient clinics.

 

- The importance of the first interview and of the patient/doctor interaction 

 

- Questionnaires, diaries and cartography of pain                                                                   

o Easy and fast recordings of the clinical picture (analogic, semantic, numerical etc)

o Complex pain questionnaires and specific, disease-oriented questionnaires

o Quality of life, ADL; Motor impairment

o Pain drawing and pain mapping. Where the signs and symptoms are perceived and found 

          

- The clinical examination of the skin sensory system                                                              

Description of the minimum instrument set needed and how to use it (hammer, tuning fork, Von Frey hairs, heat and cold, dermographic pencil) in the evaluation of sensory signs and symptoms referred to the skin

o Mechanical static, dynamic, deep somatic

o Mechanical pinprick

o Thermal (heat & cold) 

 

- The clinical examination of the chronic neuropathic pain patient.  Some pivotal hints.      

o Quantitative sensory testing 

 

- The clinical examination of muscle and visceral pain                           

Diagnosis and differential diagnosis of different forms of primary and secondary muscle pain, and of different visceral pain phenomena (true visceral pain, referred pain with and without hyperalgesia, visceral hyperalgesia, viscero-visceral hyperalgesia)

o Clinical procedures

o Instrumental procedures 

 

- Translation of symptoms into pain mechanisms: a dictionary                                   

The lecture will cover the peripheral, spinal and supraspinal mechanisms of pain as evidenced from preclinical studies but in the context translation to patients. Allodynia, hyperalgesia, ongoing pain will be covered.

o Neuropathic, inflammatory and visceral pain mechanisms

o Peripheral and central sensitization – what these may mean in terms of signs and symptoms.

o Can the actions of drugs aid us in terms of understanding pain mechanisms?

 

- The motor impairment in chronic neuropathic pain                                                               

o Voluntary, autonomic

o Peripheral, central 

 

- Pain Tournament or Europe against Pain – The First Challenge

A tournament will be organized between participants to verify the level of knowledge acquired after this session. The tournament consists of simulated cases within a range of pain topics from those most frequently seen in the outpatient setting. The aim is to make this an educational exercise while introducing the fun of a competition.

 

Diagnostic procedures

What to ask for and how to interpret it.

 

- Laboratory (blood samples for inflammatory markers, etc.)

 

- Routine and special neurophysiology testing (clinical indications and limitations)      Andrei Danilov

o Quantitative sensory testing (thermal; vibratory)

o Neurovegetative tests (non-invasive)

   Sudomotor studies (SSR; QSART Quantitative sudomotor axon reflex test)

   Vasomotor studies (photoplethysmography; laser Doppler)

   Skin temperature (thermography)

   R-R variability (Valsalva manoeuvre, tilt test)

o Microneurography

o Evoked potentials (LASER, dermatomeric, SSEP)

o Reflex responses (blink, RaIII)

o Brain mapping 

 

- Indications and limits of poorly invasive diagnostic procedures                                            

o Peripheral nerve blockade

o Electrostimulation (SCS, PNS, etc.)

o Bier’s blockade with different compounds

o Systemic lidocaine test

o Pharmacological tests 

 

- The inpatient: difficult diagnosis and difficult patients                                            

A patient is referred to a pain clinic mainly for further investigations, confirmation of the diagnostic hypothesis or to start a given treatment. Quite often they can be defined as “difficult patients”. In this setting the clinical and diagnostic tools should be used to define the type of pain precisely and determine the possible sites of action of the therapeutic options.

o The multidisciplinary approach and the critical revision of the highly complex patient’s history

o Chronic pain and the psychological profile of the difficult patient

o The neuro-psycho-social model 

 

Treatments

- Neuropathic or Nociceptive. From diagnosis to treatments.                                                  

The EFIC Schools of Montescano and Klagenfurt      

 

- Pain Tournament or Europe against Pain – The Final Challenge.

The “losers” of the First Challenge will have a second chance to tackle more complex and challenging cases of chronic pain. As for the First Challenge, the tournament will consist of simulated cases within a range of highly complex pain topics. The aim is always to make this an educational exercise but with the excitement of a competition

 

Daily Polling Sessions

Use of diagnostic work-up algorithm for clinical diagnosis in chronic pain

 

Daily Practical training

Participants will carry out exercises applying what they have learned in the morning lessons through workshops composed of small groups, interactive sessions, role playing and multimedia simulations

 

Learning questionnaires

In this setting, the clinical and diagnostic tools learned during the School will be discussed and compared, with teachers, in relation to real clinical cases