Gli instrumenti di screening devono essere applicati nella

diagnosi del DN ? Si

Nadine ATTAL

INSERM U-987Centre d’Evaluation et de Traitement de la Douleur

Hôpital Ambroise Paré, Boulogne-Billancourt FRANCE

Incontro Nazionale Neurofisiologia : Nuove StrategiControverise sulla diagnosi e terapia del dolore neuropaticoPalermo 29-30 novembre 2012

Gli instrumenti di screening

• Presentation of the main instruments • Research applications• Diagnostic workup of neuropathic pain and

clinical relevance of the screening tools

Neuropathic Pain Questionnaires

Screening/Diagnosis

Evaluation/Measurement

BASED ON SYMPTOM DESCRIPTION

IMPORTANCE OF THE LANGUAGE OF PAIN

Diagnostic value of pain descriptors (e.g. Dubuisson and Melzack, 1976, Mason et al., 1989)

Multidimensional Assessment of Chronic Pain

THE McGILL PAIN QUESTIONNAIRE

R. Melzack

Neuropathic pain

n=100

Non neuropathic pain (n = 97)

Burning 54 29

Electric shock 53 21

Beating 9 23

Cold 22 10

tingling 48 25

Itching 33 9

Dull 18 46

Tiring 35 57

Neuropathic Pain Questionnaire (NPQ)

Krause & Backonja, Clin J Pain, 2003

ID Pain Portenoy, Curr Med Res Op, 2006

Pain DetectFreynhagen et al, Curr Med Res Op, 2006

LANSS Pain Scale Bennett, Pain, 2001

DN4Bouhassira et al, Pain, 2005

Neuropathic pain screening tools

any neuropathic pain

SteP Scholz et al, PLoS Med 2009

Low back pain

Validation studies

- Selection of potentially discriminant items - Comparison of patients with or without NP- Identification of the most discriminant combinations of items

Similarities

30 66 ***Numbness

6 29 ***Itching

17 66 ***Pins and needles

16 60 ***Tingling

65 76Lancinating

17 65 ***Shooting

10 26 *Cold pain

38 49Squeezing

30 68 ***Burning 

Non-neuropathic

Pain (%)

Neuropathic Pain (%)

Differences in the clinical expression of NP

*** P<0.001 P= 0.015 Bouhassira et al. Pain 2005;114(1-2):29-36.

Differences- Inclusion and diagnostic criteria: - only peripheral neuropathic pain (LANSS, NPQ, PainDetect, IDpain) - both peripheral and central neuropathic pain (DN4)

- Design of the questionnaire: - inclusion of items related to the examination (LANSS, DN4) - self-questionnaires (NPQ, PainDetect, IDpain)

Self-administered LANSS (S-LANSS) and DN4 (DN4-Interview) have also been validated

Validations studies

- Selection of potentially discriminant items - Comparison of patients with or without NP- Identification of the most discriminant combinations of items

Similarities

Validation in mixed neuropathic pain

LBP with typicalradicular pain

LBP without radiations

Sensitivity: 80%

Specificity: 92%

Administration of theDN4 at both sites

Attal et al. J Pain 2011

Differences in the presentation of the screening tools

LANSS NPQ DN4 PainDetect IDpain

Burning + + + + +Electric shocks + + + + +Tingling, pins and needles, pricking

+ + + + +

Pain evoked by touching

+ + + + +

Numbness + + + +

Painful cold + +

Tactile

hypoesthesia+ +

Adapted from Bennett et al., Pain, 2007

"core" neuropathic pain symptoms

Sensitivity Specificity Predictive accuracy

LANSS 85% 80% 85%

NPQ 74% 76% Not

reported

DN4 83% 90% 86%

Pain Detect 85% 80% 83%

Discriminative value of the screening tools

Haanpaa et al., Pain 2011

Several comparative studies of DN4 vs others (Unal-Cevik et al., J Pain 2010; Hallstrom and Norrbrink Pain 2011 ;

Padua et al Neurol Sci 2012)

Pain qualites are probably related to mechanisms

- Several screening tools have been translated into many other languages than the original one (>30).

- The discriminant properties of some questionnaires have been confirmed into several languages.

LANSS Spanish (Perez et al., 2006); Turkish (Koc et al., 2010)

DN4 Spanish (Perez et al., 2007); Turkish (Unal-Cevik et al., 2010); Portugese (Santos et al., 2010)

Arabic, (Harifi et al., 2010) ; Dutch (Van Seventer et al 2012)

Is the language of pain universal?

Applications of NeP screening tools

1) Education/communication

1) Research applications- Epidemiology - Other research applications

3) Clinical practice

Education/information

British Study

(Torrance et al.,

J Pain 2006)

French Study

(STOPNEP)

(Bouhassira et al.,

Pain 2008)

Participants 6,000 30,000

Screening tool S-LANSS DN4-Interview

Response Rate 52.4% 81.2%

Prevalence of Chronic Pain 48% 31.7%

Prevalence of Chronic Pain with neuropathic characteristics

8.2% 6.9%

Epidemiology

These results should be interpreted with caution since the screening tools have not beenformally validated for use in the general population

0

10

20

30

40

50

60

Mental health Physical health

Pain with NC (n = 805)

Pain without NC (n = 786) No pain (n = 1237)

** **

Score (SF12)

** p < 0.01

Attal et al Pain 2011

010203040506070

Abnormal score

% **

**

**

Epidemiology

Abnormal anxiety score

Abnormal depressionscore

HAD score

Quality of life Anxiety/depression

Proportion of patients with neuropathic pain

- Neuropathic pain in diabetic patients (DN4) (VanAcker et al., 2009)

- Post-surgical pain (PainDetect, DN4) (eg, Steegers et al 2008; Von Sperling et al., 2010)

- Cancer (LANSS) (Mercadante et al., 2009 )

- Multiple sclerosis (DN4) (Padua et al Pain 2012)

Predictive factors for the development of neuropathic pain:

- Post-surgical pain (LANSS, DN4) (Martinez et al Pain 2012) - PHN: The DN4 score during the acute phase is predictive of PHN ( Bouhassira et al Pain 2011)

Pathophysiological studies

- Arthritis pain (PainDetect) (Gwylim et al Arthritis Rheum 2009)- CMT painful neuropathy (DN4) (Pazzaglia et al Pain 2010)

Therapeutic studies

- Inclusion of patients in clinical trials (Yuan et al Neurology 2009; Vranken et al Pain 2010)

Other research applications

Are screening tools really helpful for the clinical diagnosis of NP ?

• Comparison with the proposed NeuPsig diagnostic algorithm

• Conditions of use and limitations

Grading system

Pain

Pain distribution neuroanatomically plausible and History suggest relevant lesion or disease

Working hypothesis:Possible neuropathic pain

Unlikely to be neuropathic pain

Unconfirmed as neuropathic pain

Probableneuropathicpain

Definiteneuropathicpain

Confirmatory tests:

a: Negative or positive sensory signs, confined to innervation territory of the lesioned nervous structure

b: Diagnostic test confirming lesion or disease explaining neuropathic pain

Leading complaint

History

Examination

Neither

No

OneBoth

Yes

Treede et al Neurology 2008

Clinical case

• 38 years old female patient • Cervico-dorsal syringomyelia • Bilateral shoulder pain • Hypoesthesia to cold and tactile stimuli

only on the left side• Is this neuropathic pain ?

Clinical case

• Pain improved with physical therapy and aggravated by effort, no neuropathic characteristics

• DN4 : 2/10• Subsequently attributed to capsulitis

Non neuropathic pain in a lesioned area

Pain

Pain distribution neuroanatomically plausible and History suggest relevant lesion or disease

Working hypothesis:Possible neuropathic pain

Unlikely to be neuropathic pain

Unconfirmed as neuropathic pain

Probableneuropathicpain

Definiteneuropathicpain

Confirmatory tests:

a: Negative or positive sensory signs, confined to innervation territory of the lesioned nervous structure

b: Diagnostic test confirming lesion or disease explaining neuropathic pain

Leading complaint

History

Examination

Grading system

Neither

No

OneBoth

Yes

Treede et al Neurology 2008

Symptoms ?

Michel et al, Revue Neurol 1990

Pain due to cortical stroke

Screening tools are correlated to the degree of certainty of the

nervous lesion Bennett et al, Pain, 2006

Also found by Guastella et al Pain 2011

Conditions of use and limitations of the screening tools

- Screening tools were validated in patients with only one pain location

or pain predominantly in one location.

In patients with multiple pain locations, screening tools should be administeredsuccessively to the different locations.

tingling burning

tinglingnumbness

electric shockspins and needles

Screening tools should not be used in patients with diffuse pain (e.g. fibromyalgia)

Perrot et al., Pain 2010

- Screening tools fail to identify 10-20% of patients with clinician

diagnosed neuropathic pain.

Conditions of use and limitations of the screening tools

Screening tools do not replace the clinical judgement

- Screening tools do not give information about the cause of pain.

- Screening tools are not adapted to assess the effects of treatment.

Bouhassira and Attal Pain 2011

Conditions of use and limitations of the screening tools

• Lack sensitivity if pain is mild (Perez et al, 2007)

The ideal diagnostic workup

1/Screening : is the pain neuropathic ?

Screening tools

2/ Diagnosis Clinical context

Painful area Clinical examination

Complementary tests as needed Bouhassira and Attal Pain 2010

Screening tools have contributed to « demystify » neuropathic pain.

Provided they are used properly, screening tools can be used as a first step in the diagnostic workup, but should be combined with a general assessment of the patients and do not replace clinical judgment

Gli instrumenti di screening devono essere applicati nella diagnosi del DN ?

Si : devono applicati nella screening

H. Alchaar (Nice)F. Boureau (Paris)

B. Brochet (Bordeaux)J. Bruxelle (Paris)G. Cunin (Paris)

M. Lanteri-Minet (Nice)B. Laurent (Saint-Etienne)

G. Mick (Voiron)A. Serrie (Paris)D. Valade (Paris)

DN4 validation

UNIVERSITÉ VERSAILLES SAINT-QUENTIN