1. May QST offer useful infos for the diagnosis of neuropathic pain? Yes  David Yarnitsky No  Valeria Tugnoli Discussants: Marcello Romano, Stefano Tamburin, Incontro Nazionale Neurofisiologia: Nuove Strategie “Controversie sulla diagnosi e terapia del dolore neuropatico” Palermo, 29-30 novembre 2012

2. Conclusions Stefano Tamburin Palermo, 29-30 novembre 2012

3. QST for NP diagnosis: pros QST may document loss-of-fx changes in small fibers and central pain pathways (EDX may not)

4. QST for NP diagnosis: pros QST may document loss-of-fx changes in small fibers and central pain pathways (EDX may not) QST may help to apply the NeuPSIG algorithm for the diagnosis of NP (EDX may help too)

6. QST for NP diagnosis: pros QST may document loss-of-fx changes in small fibers and central pain pathways (EDX may not) QST may help to apply the NeuPSIG algorithm for the diagnosis of NP (EDX may help too) QST may separate NP from nociceptive pain (?)

8. 10 pts with chronic musculoskeletal pain (non NP)

9. QST for NP diagnosis: pros QST may document loss-of-fx changes in small fibers and central pain pathways (EDX may not) QST may help to apply the NeuPSIG algorithm for the diagnosis of NP (EDX may help too) QST may separate NP from nociceptive pain (?) QST may follow pts up (natural history, treatment)

10. QST for NP diagnosis: pros QST may document loss-of-fx changes in small fibers and central pain pathways (EDX may not) QST may help to apply the NeuPSIG algorithm for the diagnosis of NP (EDX may help too) QST may separate NP from nociceptive pain (?) QST may follow pts up (natural history, treatment) QST may explore gain-of-fx changes (EDX does not)

11. QST for NP diagnosis: pros QST may document loss-of-fx changes in small fibers and central pain pathways (EDX may not) QST may help to apply the NeuPSIG algorithm for the diagnosis of NP (EDX may help too) QST may separate NP from nociceptive pain (?) QST may follow pts up (natural history, treatment) QST may explore gain-of-fx changes (EDX does not) QST may predict development of NP in pts at risk

12. QST for NP diagnosis: pros QST may document loss-of-fx changes in small fibers and central pain pathways (EDX may not) QST may help to apply the NeuPSIG algorithm for the diagnosis of NP (EDX may help too) QST may separate NP from nociceptive pain (?) QST may follow pts up (natural history, treatment) QST may explore gain-of-fx changes (EDX does not) QST may predict development of NP in pts at risk QST may predict response to NP drugs

13. QST for NP diagnosis: cons No standardized and widely accepted QST protocol and normal range of values

14. Palermo, 29-30 novembre 2012

15. QST for NP diagnosis: cons No standardized and widely accepted QST protocol and normal range of values Test-retest and interobserver reproducibility are unclear

16. QST for NP diagnosis: cons No standardized and widely accepted QST protocol and normal range of values Test-retest and interobserver reproducibility are unclear QST cannot define the anatomical level of changes (EDX and EPs can)

17. QST for NP diagnosis: cons No standardized and widely accepted QST protocol and normal range of values Test-retest and interobserver reproducibility are unclear QST cannot define the anatomical level of changes (EDX and EPs can) QST is a subjective measure (as well as pain, VAS and NRS)

18. QST for NP diagnosis: cons No standardized and widely accepted QST protocol and normal range of values Test-retest and interobserver reproducibility are unclear QST cannot define the anatomical level of changes (EDX and EPs can) QST is a subjective measure (as well as pain, VAS and NRS) QST cannot differentiate real from simulated and psychogenic changes (medico-legal issues)

19. QST for NP diagnosis: cons No standardized and widely accepted QST protocol and normal range of values Test-retest and interobserver reproducibility are unclear QST cannot define the anatomical level of changes (EDX and EPs can) QST is a subjective measure (as well as pain, VAS and NRS) QST cannot differentiate real from simulated and psychogenic changes (medico-legal issues) QST is time consuming, expensive, needs a long training and is available only in specialized centers

20. Principal limitations of methods for studying small fiber function LIMITATIONSBED SIDE QSTLEPBIOPSY COLLABORATION NEEDED +++/-- TECHNICAL DIFFICULTY OF EXECUTION AND MEASUREMENT --++ INVASIVENESS ---+ IDENTIFICATION OF LESIONAL SITE (CENTRAL vs PERIPHERAL) +/---+ HIGH COST -+++ AVAILABLE ONLY IN SPECIALIZED CENTERS -+++

21. QST for NP diagnosis: cons No standardized and widely accepted QST protocol and normal range of values Test-retest and interobserver reproducibility are unclear QST cannot define the anatomical level of changes (EDX and EPs can) QST is a subjective measure (as well as pain, VAS and NRS) QST cannot differentiate real from simulated and psychogenic changes (medico-legal issues) QST is time consuming, expensive, needs a long training and is available only in specialized centers QST cannot substitute bedside evaluation (as well as EDX)

22. Palermo, 29-30 novembre 2012