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

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 29-30 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 Evaluation/ Measurement Screening/ Diagnosis BASED ON SYMPTOM DESCRIPTION IMPORTANCE OF THE LANGUAGE OF PAIN

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

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

8. Differences in the clinical expression of NP Neuropathic Pain (%) Non-neuropathic Pain (%) 30 Burning  68 *** 38 Squeezing 49 10 Cold pain 26 * 17 Shooting 65 *** 65 Lancinating 76 Tingling 16 60 *** Pins and needles 17 66 *** Itching 6 29 *** Numbness 66 *** 30 *** P<0.001 P= 0.015 Bouhassira et al. Pain 2005;114(1-2):29-36.

9. Validations studies Similarities • Selection of potentially discriminant items • Comparison of patients with or without NP • Identification of the most discriminant combinations of items • 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. Administration of the DN4 at both sites Sensitivity: 80% Specificity: 92% LBP with typical radicular pain LBP without radiations Attal et al. J Pain 2011 Validation in mixed neuropathic pain

11. Differences in the presentation of the screening tools

12. "core" neuropathic pain symptoms Adapted from Bennett et al., Pain, 2007

13. Discriminative value of the screening tools 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) 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. These results should be interpreted with caution since the screening tools have not been formally validated for use in the general population Epidemiology

18. Epidemiology Quality of life Pain with NC (n = 805) Anxiety/depression Pain without NC (n = 786) Score (SF12) No pain (n = 1237) HAD score 60 % 70 50 ** 60 ** 40 50 30 40 ** 30 20 ** 20 ** 10 10 0 0 Mental health Physical health Abnormal score Abnormal depression score Abnormal anxiety 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)

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. Unlikely to be neuropathic pain Working hypothesis:Possible neuropathic pain Unconfirmed as neuropathic pain Definiteneuropathicpain Probableneuropathicpain Grading system Pain Leading complaint Pain distribution neuroanatomically plausible and History suggest relevant lesion or disease History No Yes Examination 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 Neither Both One 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. Non neuropathic pain in a lesioned area Clinical case • Pain improved with physical therapy and aggravated by effort, no neuropathic characteristics • DN4 : 2/10 • Subsequently attributed to capsulitis

25. Unlikely to be neuropathic pain Working hypothesis:Possible neuropathic pain Unconfirmed as neuropathic pain Definiteneuropathicpain Probableneuropathicpain Grading system Symptoms ? Pain Leading complaint Pain distribution neuroanatomically plausible and History suggest relevant lesion or disease History No Yes Examination 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 Neither Both One Treede et al Neurology 2008

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

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

30. Conditions of use and limitations of the screening tools Screening tools do not replace the clinical judgement • Screening tools fail to identify 10-20% of patients with clinician diagnosed neuropathic pain. • 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. 2/ Diagnosis Clinical context Painful area Clinical examination Complementary tests as needed The ideal diagnostic workup 1/Screening : is the pain neuropathic ? Screening tools 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. DN4 validation 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) UNIVERSITÉ VERSAILLES SAINT-QUENTIN