1. 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
Controverise sulla diagnosi e terapia del dolore neuropatico
Palermo novembre 2012

2. Gli instrumenti di screening
Presentation of the main instruments
Research applications
Diagnostic workup of neuropathic pain and clinical relevance of the screening tools

3. Neuropathic Pain Questionnaires
Screening/
Diagnosis
Evaluation/
Measurement
BASED ON SYMPTOM DESCRIPTION
IMPORTANCE OF THE LANGUAGE OF PAIN

4. Diagnostic value of pain descriptors
Multidimensional Assessment of Chronic Pain
THE McGILL PAIN QUESTIONNAIRE
R. Melzack
Diagnostic value of pain descriptors
(e.g. Dubuisson and Melzack, 1976, Mason et al., 1989)

5. Non neuropathic pain (n = 97)
Burning 54 29
Electric shock 53 21
Beating 9 23
Cold 22 10
tingling 48 25
Itching 33
Dull 18 46
Tiring 35 57

6. Neuropathic pain screening tools
Questionnaire (NPQ)
Krause & Backonja, Clin J Pain, 2003
ID Pain
Portenoy, Curr Med Res Op, 2006
Pain Detect
Freynhagen et al, Curr Med Res Op, 2006
LANSS Pain Scale
Bennett, Pain, 2001
DN4
Bouhassira et al, Pain, 2005
Neuropathic pain screening tools
any
neuropathic pain
SteP
Scholz et al, PLoS Med 2009
Low back pain

7. Validation studies Similarities
Selection of potentially discriminant items
Comparison of patients with or without NP
Identification of the most discriminant combinations of items
Similarities

8. Differences in the clinical expression of NP
Neuropathic Pain (%)
Non-neuropathic
Pain (%)
Burning 
68 *** 30
Squeezing 49 38
Cold pain
26 * 10
Shooting
65 *** 17
Lancinating 76 65
Tingling
60 *** 16
Pins and needles
66 *** 17
Itching
29 *** 6
Numbness
66 *** 30
*** P< P= 0.015
Bouhassira et al. Pain 2005;114(1-2):29-36.

9. Validations studies Similarities Differences
Selection of potentially discriminant items
Comparison of patients with or without NP
Identification of the most discriminant combinations of items
Similarities
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

10. Validation in mixed neuropathic pain
LBP with typical
radicular pain
LBP without
radiations
Sensitivity: 80%
Specificity: 92%
Administration of the
DN4 at both sites
Attal et al. J Pain 2011

11. Differences in the presentation of the screening tools

12. "core" neuropathic pain symptoms +
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

13. Discriminative value of the screening tools
Sensitivity
Specificity
Predictive accuracy
LANSS
85%
80%
NPQ
74%
76%
Not
reported
DN4
83%
90%
86%
Pain Detect
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)
Haanpaa et al., Pain 2011

14. Is the language of pain universal?
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?
Pain qualites are probably related to mechanisms

15. Applications of NeP screening tools
Education/communication
Research applications
- Epidemiology
Other research applications
3) Clinical practice

16. Education/information

17. Epidemiology 8.2% 6.9% 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%
These results should be interpreted with caution since the screening tools have not been
formally validated for use in the general population

18. Epidemiology Quality of life Anxiety/depression Attal et al Pain 2011
Pain with NC (n = 805)
Anxiety/depression
Pain without NC (n = 786)
Score (SF12)
No pain (n = 1237)
HAD score 60 % 50 70 ** ** 60 40 50 30 40 ** 30 20 20 ** 10 ** 10
Mental health
Physical health
Abnormal
score
Abnormal
anxiety
score
Abnormal
depression
score
** p < 0.01
Attal et al Pain 2011

19. 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)

20. Other research applications
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

21. Are screening tools really helpful for the clinical diagnosis of NP ?
Comparison with the proposed NeuPsig diagnostic algorithm
Conditions of use and limitations

22. Grading system Treede et al Neurology 2008 Neither No One Both Yes
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
Probable neuropathic pain
Definite neuropathic pain
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
One
Both
Yes
Treede et al Neurology 2008

23. 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 ?

24. 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

25. Symptoms ? Grading system Treede et al Neurology 2008 Neither No One
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
Probable neuropathic pain
Definite neuropathic pain
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
One
Both
Yes
Treede et al Neurology 2008
Symptoms ?

26. Pain due to cortical stroke
Michel et al, Revue Neurol 1990

27. 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

28. 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 administered
successively to the different locations.

29. Screening tools should not be used in patients
with diffuse pain (e.g. fibromyalgia)
tingling
burning
numbness
electric shocks
pins and needles
Perrot et al., Pain 2010

30. Conditions of use and limitations
of the screening tools
Screening tools fail to identify 10-20% of patients with clinician diagnosed neuropathic pain.
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

31. Conditions of use and limitations
of the screening tools
Lack sensitivity if pain is mild (Perez et al, 2007)

32. 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

33. Gli instrumenti di screening devono essere applicati nella diagnosi del DN ? Si : devono applicati nella screening
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

34. M. Lanteri-Minet (Nice) B. Laurent (Saint-Etienne) G. Mick (Voiron)
UNIVERSITÉ VERSAILLES SAINT-QUENTIN
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