gli instrumenti di screening devono essere applicati nella diagnosi del dn ? si
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Gli instrumenti di screening devono essere applicati nella diagnosi del DN ? Si. Nadine ATTAL INSERM U-987 Centre d ’ Evaluation et de Traitement de la Douleur Hôpital Ambroise Paré, Boulogne-Billancourt FRANCE. Incontro Nazionale Neurofisiologia : Nuove Strategi - PowerPoint PPT PresentationTRANSCRIPT
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