Quantitative sensory testing measures individual pain responses in emergency department patients

Kevin J Duffy, Katharyn L Flickinger, Jeffrey T Kristan, Melissa J Repine, Alexandro Gianforcaro, Rebecca B Hasley, Saad Feroz, Jessica M Rupp, Jumana Al-Baghli, Maria L Pacella, Brian P Suffoletto, Clifton W Callaway, Kevin J Duffy, Katharyn L Flickinger, Jeffrey T Kristan, Melissa J Repine, Alexandro Gianforcaro, Rebecca B Hasley, Saad Feroz, Jessica M Rupp, Jumana Al-Baghli, Maria L Pacella, Brian P Suffoletto, Clifton W Callaway

Abstract

Background: Refining and individualizing treatment of acute pain in the emergency department (ED) is a high priority, given that painful complaints are the most common reasons for ED visits. Few tools exist to objectively measure pain perception in the ED setting. We speculated that variation in perception of fixed painful stimuli would explain individual variation in reported pain and response to treatment among ED patients.

Materials and methods: In three studies, we 1) describe performance characteristics of brief quantitative sensory testing (QST) in 50 healthy volunteers, 2) test effects of 10 mg oxycodone versus placebo on QST measures in 18 healthy volunteers, and 3) measure interindividual differences in nociception and treatment responses in 198 ED patients with a painful complaint during ED treatment. QST measures adapted for use in the ED included pressure sensation threshold, pressure pain threshold (PPT), pressure pain response (PPR), and cold pain tolerance (CPT) tests.

Results: First, all QST measures had high inter-rater reliability and test-retest reproducibility. Second, 10 mg oxycodone reduced PPR, increased PPT, and prolonged CPT. Third, baseline PPT and PPR revealed hyperalgesia in 31 (16%) ED subjects relative to healthy volunteers. In 173 (88%) ED subjects who completed repeat testing 30 minutes after pain treatment, PPT increased and PPR decreased (Cohen's dz 0.10-0.19). Verbal pain scores (0-10) for the ED complaint decreased by 2.2 (95% confidence intervals [CI]: 1.9, 2.6) (Cohen's dz 0.97) but did not covary with the changes in PPT and PPR (r=0.05-0.13). Treatment effects were greatest in ED subjects with a history of treatment for anxiety or depression (Cohen's dz 0.26-0.43) or with baseline hyperalgesia (Cohen's dz 0.40-0.88).

Conclusion: QST reveals individual differences in perception of fixed painful stimuli in ED patients, including hyperalgesia. Subgroups of ED patients with hyperalgesia and psychiatric history report larger treatment effects on ED pain and QST measures.

Keywords: anxiety; depression; emergency department; hyperalgesia; opioid; quantitative sensory testing.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Response of QST measures to 10 mg oxycodone in healthy volunteers. Notes: Group median and intraquartile ranges are depicted for pressure pain response at 50 N/cm2 (A), at 75 N/cm2 (B), pressure pain threshold (C), pressure sensation threshold (D), and cold pain threshold (E). After oxycodone, the response at 50 N/cm2, response at 75 N/cm2, and cold pain response were decreased relative to baseline at 60 and 90 minutes (*p<0.05). Abbreviations: QST, quantitative sensory testing.
Figure 2
Figure 2
Subjects recruited from ED patients, and reasons for exclusion. Abbreviations: ED, emergency department; QST, quantitative sensory testing.
Figure 3
Figure 3
Distribution of pain response at 50 N/cm2 (A) and at 75 N/cm2 (B) and pressure pain threshold (C) in healthy volunteers and in ED subjects (VAS in cm). Notes: The distribution of pressure pain thresholds and pain response at 75 N/cm2 differed between cohorts. Lower pain thresholds were more frequent among ED subjects, and maximal pain responses (>9 cm on VAS) were more frequent in ED subjects. Abbreviation: ED, emergency department; VAS, Visual Analog Scale.

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