Systematic mechanism-orientated approach to chronic pancreatitis pain

Table 1 Nijmegen-Aalborg screening quantitative sensory testing paradigm[18]

NASQ paradigm
Standard QST
Sites (bilateral)	Trapezius muscle, thenar eminence, rectus femoris, abductor hallucis, site of pain
Thresholds	Pressure pain, electric detection, electric pain detection, electric pain tolerance
Conditioned pain modulation
Sites	1 Ice-water bucket (non-dominant hand)
	2 Thresholds on rectus femoris
Thresholds (before ice-water/180 s after)	Pressure pain, electric pain tolerance

Quantitative sensory testing (QST) measurements to detect central sensitization and pro- or anti-nociceptive shifts in descending pain modulation. NASQ: Nijmegen-Aalborg screening QST.

Table 2 Schematic for systematic mechanism-orientated approach to chronic pancreatitis pain

Questions	Issue	QST	Therapy
Nociceptive source?	Site/agressiveness	Local hyperalgesia	Treat or deafferent
Nociceptive transmission?	Nerve damage	Territorial thermal hyperalgesia	Treat (cave CS!)
Central pain processing?	Central sensitisation	Spreading hyperalgesia	Antihyperalgesia (ketamine, gabapentinoids)
	Pronociceptive modulation	Sensitisation to CPM paradigm	Activate DI (TCA, NRI)
Autonomy of central pain processing?	Autonomy	No changes in thresholds after therapy	Traget altered central processing

Autonomy means that alterations in central pain processing have become independent of peripheral nociceptive drive. CPM: Conditioned pain modulation; DI: Descending inhibition; TCA: Tricyclic antidepressant; NRI: Noradrenaline reuptake inhibitor; QST: Quantitative sensory testing. This figure is based on the original figure of ref [18].