Incontro Nazionale Neurofisiologia: Nuove StrategieIncontro Nazionale Neurofisiologia: Nuove Strategie

“Controversie sulla diagnosi e terapia del dolore neuropatico”

Palermo, 29-30 novembre 2012

G. Sandrini

Dipartimento di Neurologia e Neuroriabilitazione Fondazione "Istituto Neurologico Nazionale C. Mondino" – IRCCS

Università di Pavia, Pavia

Gli strumenti di screening (DN4, etc.) devono essere applicati nella diagnosi del dolore

neuropatico?

SI: Attal vs NO: Sandrini

“BASTIAN CONTRARIO”

“Never say yes”

CRITICISM

“That’s fine, but...”

VISUAL vs VERBAL vs NUMERICAL SCALES:VISUAL vs VERBAL vs NUMERICAL SCALES:ARE THEY EQUIVALENT? ARE THEY EQUIVALENT?

A Williamson, B Hoggart

Journal of Clinical Nursing 2005, 14:798-804 (1)

VISUAL vs VERBAL vs NUMERICAL SCALES:VISUAL vs VERBAL vs NUMERICAL SCALES:ARE THEY EQUIVALENT? ARE THEY EQUIVALENT?

VAS most difficult –VRS less sensitive VAS most difficult –VRS less sensitive

Journal of Clinical Nursing 2005, 14:798-804 (2)

NEUROPATHIC NOCICEPTIVE PAIN:NEUROPATHIC NOCICEPTIVE PAIN:DIFFICULT TO DISTINGUISH?DIFFICULT TO DISTINGUISH?

L Padua et al.

Neurol Sci 2009, 30:99-106

DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:CAN WE QUANTIFY ALL THE ASPECTS? CAN WE QUANTIFY ALL THE ASPECTS?

Pain “As-if”Pain “As-if”

J Katz et al.

Surg Clin North Am. 1999, 79 (2): 231-52 ( 1)

DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:CAN WE QUANTIFY ALL THE ASPECTS? CAN WE QUANTIFY ALL THE ASPECTS? Pain is not an unidimensional experiencePain is not an unidimensional experience

Surg Clin North Am. 1999, 79 (2): 231-52 (2)

DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:CAN WE QUANTIFY ALL THE ASPECTS? CAN WE QUANTIFY ALL THE ASPECTS?

Pain as personal,subjective experiencePain as personal,subjective experience

Surg Clin North Am. 1999, 79 (2): 231-52 (3)

DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:CAN WE QUANTIFY ALL THE ASPECTS? CAN WE QUANTIFY ALL THE ASPECTS?

Aeterogeneity of pain conditions and factors examinedAeterogeneity of pain conditions and factors examined

Surg Clin North Am. 1999, 79 (2): 231-52 (4)

DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:CAN WE QUANTIFY ALL THE ASPECTS? CAN WE QUANTIFY ALL THE ASPECTS?

Sensitivity of MPQ related to intensity of painSensitivity of MPQ related to intensity of pain

Surg Clin North Am. 1999, 79 (2): 231-52 (5)

DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:CAN WE QUANTIFY ALL THE ASPECTS? CAN WE QUANTIFY ALL THE ASPECTS?

Anxiety and psychological disturbance influence on MPQ Anxiety and psychological disturbance influence on MPQ

Surg Clin North Am. 1999, 79 (2): 231-52 (6)

DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:CAN WE QUANTIFY ALL THE ASPECTS? CAN WE QUANTIFY ALL THE ASPECTS?

Behavioral Approaches better in children and adults with Behavioral Approaches better in children and adults with decreased ability to comunicatedecreased ability to comunicate

Surg Clin North Am. 1999, 79 (2): 231-52 (7)

DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:CAN WE QUANTIFY ALL THE ASPECTS? CAN WE QUANTIFY ALL THE ASPECTS?

Habituation phenomenaHabituation phenomena

Surg Clin North Am. 1999, 79 (2): 231-52 (8)

VISUAL vs VERBAL vs NUMERICAL SCALES:VISUAL vs VERBAL vs NUMERICAL SCALES:ARE THEY EQUIVALENT? ARE THEY EQUIVALENT?

Different complianceDifferent compliance

J Pain Symptom Manage 2011, 41 (6): 1073-93 (1)

MJ Hjermstad et al.

VISUAL vs VERBAL vs NUMERICAL SCALES:VISUAL vs VERBAL vs NUMERICAL SCALES:ARE THEY EQUIVALENT? ARE THEY EQUIVALENT?

Differences in patients preferencesDifferences in patients preferences

J Pain Symptom Manage 2011, 41 (6): 1073-93 (2)

VISUAL vs VERBAL vs NUMERICAL SCALES:VISUAL vs VERBAL vs NUMERICAL SCALES:ARE THEY EQUIVALENT? ARE THEY EQUIVALENT?

No agreement about the recommendations No agreement about the recommendations

J Pain Symptom Manage 2011, 41 (6): 1073-93 (3)

THE PHARMACOLOGICAL TREATMENT: THE PHARMACOLOGICAL TREATMENT: THE NP SCALES COVER ALL THE ASPECTS OF THE THE NP SCALES COVER ALL THE ASPECTS OF THE

CLINICAL RESPONSE?CLINICAL RESPONSE?

European Journal of Neurology 2010, 17: 1113-1123

N Attal et al.

THE NOCICEPTIVE PAIN: THE NOCICEPTIVE PAIN: ARE THE SAME SCALES USEFUL OR NOT? ARE THE SAME SCALES USEFUL OR NOT?

A poorly investigated issueA poorly investigated issue

GA Hawker et al.

Arthritis Care Res 2011, 63 Suppl 11:240-52

THE NOCICEPTIVE PAIN: THE NOCICEPTIVE PAIN: ARE THE SAME SCALES USEFUL OR NOT? ARE THE SAME SCALES USEFUL OR NOT?

MPQ is useful to discriminate different type of pain,but…..MPQ is useful to discriminate different type of pain,but…..

Arthritis Care Res 2011, 63 Suppl 11:240-52

ASSESSING NP IN CLINICAL TRIALS:ASSESSING NP IN CLINICAL TRIALS:THE SCALES ARE ENOUGH? THE SCALES ARE ENOUGH?

The role of Quantitative Sensory TestingThe role of Quantitative Sensory Testing

N Attal et al.

European Journal of Pain 2011, 15: 441-443 (1)

What is the relevance of symptom oriented classifications of NP?

ASSESSING NP IN CLINICAL TRIALS:ASSESSING NP IN CLINICAL TRIALS:THE SCALES ARE ENOUGH? THE SCALES ARE ENOUGH?

Different drugs and different effectsDifferent drugs and different effects

European Journal of Pain 2011, 15: 441-443 (2)

Assessing symptoms and signs in clinical trials of NP

ASSESSING NP IN CLINICAL TRIALS:ASSESSING NP IN CLINICAL TRIALS:THE SCALES ARE ENOUGH? THE SCALES ARE ENOUGH?

QST is fundamental in therapeutical trialQST is fundamental in therapeutical trial

European Journal of Pain 2011, 15: 441-443 (3)

Recommendations on sensory profiling to increase therapeutic prediction

DIAGNOSIS AND ASSESSMENT OF NP:DIAGNOSIS AND ASSESSMENT OF NP:THE MAIN QUESTIONS THE MAIN QUESTIONS

D Bouhassira, N Attal

Pain 2011, 152:74-83 (1)

Importance of the language of neuropathic pain: the advent and rise of screening tools

DIAGNOSIS AND ASSESSMENT OF NP:DIAGNOSIS AND ASSESSMENT OF NP:THE MAIN QUESTIONS THE MAIN QUESTIONS

Pain 2011, 152:74-83 (2)

Description and discriminant properties of the screening tools

DIAGNOSIS AND ASSESSMENT OF NP:DIAGNOSIS AND ASSESSMENT OF NP:THE MAIN QUESTIONS THE MAIN QUESTIONS

Pain 2011, 152:74-83 (3)

Conditions of use and limitations of the screening tools

DIAGNOSIS AND ASSESSMENT OF NP:DIAGNOSIS AND ASSESSMENT OF NP:THE MAIN QUESTIONS THE MAIN QUESTIONS

Pain 2011, 152:74-83 (4)

The challenge of neuropathic pain measurement: what could be the role of the symptom-based questionnaires?

The Neuropathic pain Scale

DIAGNOSIS AND ASSESSMENT OF NP:DIAGNOSIS AND ASSESSMENT OF NP:THE MAIN QUESTIONS THE MAIN QUESTIONS

Pain 2011, 152:74-83 (5)

Other questionnaires

DIAGNOSIS AND ASSESSMENT OF NP:DIAGNOSIS AND ASSESSMENT OF NP:THE MAIN QUESTIONS THE MAIN QUESTIONS

Pain 2011, 152:74-83 (6)

Are neuropathic pain symptoms or dimensions related to the etiology?

DIAGNOSIS AND ASSESSMENT OF NP:DIAGNOSIS AND ASSESSMENT OF NP:THE MAIN QUESTIONS THE MAIN QUESTIONS

Pain 2011, 152:74-83 (7)

Do pain symptoms tell us something about the pathophysiological mechanisms?

NP ASSESSMENT QUESTIONNAIRE: NP ASSESSMENT QUESTIONNAIRE: A ROLE IN THE GUIDELINES?A ROLE IN THE GUIDELINES?

G Cruccu et al.

European Journal of Neurology 2010, 17:1010-1018

Screening and assessment tools

DN4 QUESTIONNAIRE: AETIOLOGY IS RELEVANT? DN4 QUESTIONNAIRE: AETIOLOGY IS RELEVANT?

N Attal et al.

J Pain 2011, 12 (10):1080-1087 (1)

DN4 QUESTIONNAIRE: AETIOLOGY IS RELEVANT? DN4 QUESTIONNAIRE: AETIOLOGY IS RELEVANT?

J Pain 2011, 12 (10):1080-1087 (2)

SCREENING TOOLS IN NP: SCREENING TOOLS IN NP: ARE THERE LIMITATIONS IN CLINICAL PRACTICE AND ARE THERE LIMITATIONS IN CLINICAL PRACTICE AND

RESEARCH? RESEARCH?

Pain 2007, 127:199-203

Role of screening tools in clinical practice and research

Bridging the gap between definition and diagnosis

NP: THE GUIDELINES ARE APPLIED IN CLINICAL NP: THE GUIDELINES ARE APPLIED IN CLINICAL PRACTICE?PRACTICE?

G Cruccu, N Attal

Pain 2012, 153:740-741

NPS: ARE ABLE TO IDENTIFY THE SUBGROUPS?NPS: ARE ABLE TO IDENTIFY THE SUBGROUPS?

SG Bradley

Neurology 1997, 48:332-338

CONCLUSIONSCONCLUSIONS

NP scales have limits, but…NP scales have limits, but…

We can improve their usefulness byWe can improve their usefulness by::

Evaluating all the clinical aspects in the patient Using instrumental tests Using other scales exploring other parameters (i.e. QL, etc) Using both verbal and numerical rating scales Considering possible coexistence of nociceptive pain Exploring aetiology Identifying subgroups

DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN:CAN WE QUANTIFY ALL THE ASPECTS? (7)CAN WE QUANTIFY ALL THE ASPECTS? (7)

Surg Clin North Am. 1999, 79 (2): 231-52

VISUAL vs VERBAL vs NUMERICAL SCALES:VISUAL vs VERBAL vs NUMERICAL SCALES:ARE THEY EQUIVALENT? (2)ARE THEY EQUIVALENT? (2)

J Pain Symptom Manage 2011, 41 (6): 1073-93

VISUAL vs VERBAL vs NUMERICAL SCALES:VISUAL vs VERBAL vs NUMERICAL SCALES:ARE THEY EQUIVALENT? (3)ARE THEY EQUIVALENT? (3)

J Pain Symptom Manage 2011, 41 (6): 1073-93

VISUAL vs VERBAL vs NUMERICAL SCALES:VISUAL vs VERBAL vs NUMERICAL SCALES:ARE THEY EQUIVALENT? (6)ARE THEY EQUIVALENT? (6)

J Pain Symptom Manage 2011, 41 (6): 1073-93

Conclusions

THE NOCICEPTIVE PAIN: THE NOCICEPTIVE PAIN: ARE THE SAME SCALES USEFUL OR NOT? (2)ARE THE SAME SCALES USEFUL OR NOT? (2)

Arthritis Care Res 2011, 63 Suppl 11:240-52

THE NOCICEPTIVE PAIN: THE NOCICEPTIVE PAIN: ARE THE SAME SCALES USEFUL OR NOT? (4)ARE THE SAME SCALES USEFUL OR NOT? (4)

Arthritis Care Res 2011, 63 Suppl 11:240-52

THE NOCICEPTIVE PAIN: THE NOCICEPTIVE PAIN: ARE THE SAME SCALES USEFUL OR NOT? (5)ARE THE SAME SCALES USEFUL OR NOT? (5)

Arthritis Care Res 2011, 63 Suppl 11:240-52

THE NOCICEPTIVE PAIN: THE NOCICEPTIVE PAIN: ARE THE SAME SCALES USEFUL OR NOT? (6)ARE THE SAME SCALES USEFUL OR NOT? (6)

Arthritis Care Res 2011, 63 Suppl 11:240-52

SCREENING TOOLS IN NP: SCREENING TOOLS IN NP: ARE THERE LIMITATIONS IN CLINICAL PRACTICE AND ARE THERE LIMITATIONS IN CLINICAL PRACTICE AND

RESEARCH? (1)RESEARCH? (1)

MI Bennett et al.

Pain 2007, 127:199-203

Limitations

Independent validation

NPSI: FROM EXPERIMENTAL TO CLINICAL PAINNPSI: FROM EXPERIMENTAL TO CLINICAL PAIN

D Bouhassira

Pain 2004, 108:248-257