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“ Controversie sulla diagnosi e terapia del dolore neuropatico ”. Incontro Nazionale Neurofisiologia: Nuove Strategie. Palermo, 29-30 novembre 2012. G. Sandrini. Dipartimento di Neurologia e Neuroriabilitazione Fondazione "Istituto Neurologico Nazionale C. Mondino" – IRCCS

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Incontro nazionale neurofisiologia nuove strategie

Controversie sulla diagnosi e terapia del dolore neuropatico”

Incontro Nazionale Neurofisiologia: Nuove Strategie

Palermo, 29-30 novembre 2012

G. Sandrini

Dipartimento di Neurologia e Neuroriabilitazione

Fondazione "Istituto Neurologico Nazionale C. Mondino" – IRCCS

Università di Pavia, Pavia


Incontro nazionale neurofisiologia nuove strategie
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 are they equivalent
VISUAL vs VERBAL vs NUMERICAL SCALES: applicati nella diagnosi del dolore neuropatico?ARE THEY EQUIVALENT?

A Williamson, B Hoggart

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


Visual vs verbal vs numerical scales are they equivalent vas most difficult vrs less sensitive
VISUAL vs VERBAL vs NUMERICAL SCALES: applicati nella diagnosi del dolore neuropatico?ARE THEY EQUIVALENT? VAS most difficult –VRS less sensitive

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


Neuropathic nociceptive pain difficult to distinguish
NEUROPATHIC NOCICEPTIVE PAIN: applicati nella diagnosi del dolore neuropatico?DIFFICULT TO DISTINGUISH?

L Padua et al.

Neurol Sci 2009, 30:99-106


Dimensions of pain experience and language of pain can we quantify all the aspects pain as if
DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN: applicati nella diagnosi del dolore neuropatico?CAN WE QUANTIFY ALL THE ASPECTS? Pain “As-if”

J Katz et al.

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


Incontro nazionale neurofisiologia nuove strategie
DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN: applicati nella diagnosi del dolore neuropatico?CAN WE QUANTIFY ALL THE ASPECTS? Pain is not an unidimensional experience

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


Incontro nazionale neurofisiologia nuove strategie
DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN: applicati nella diagnosi del dolore neuropatico?CAN WE QUANTIFY ALL THE ASPECTS? Pain as personal,subjective experience

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


Incontro nazionale neurofisiologia nuove strategie

DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN: applicati nella diagnosi del dolore neuropatico?CAN WE QUANTIFY ALL THE ASPECTS? Aeterogeneity of pain conditions and factors examined

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


Incontro nazionale neurofisiologia nuove strategie
DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN: applicati nella diagnosi del dolore neuropatico?CAN WE QUANTIFY ALL THE ASPECTS? Sensitivity of MPQ related to intensity of pain

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


Incontro nazionale neurofisiologia nuove strategie

DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN: applicati nella diagnosi del dolore neuropatico?CAN WE QUANTIFY ALL THE ASPECTS? Anxiety and psychological disturbance influence on MPQ

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


Incontro nazionale neurofisiologia nuove strategie

DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN: applicati nella diagnosi del dolore neuropatico?CAN WE QUANTIFY ALL THE ASPECTS? Behavioral Approaches better in children and adults with decreased ability to comunicate

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


Incontro nazionale neurofisiologia nuove strategie
DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN: applicati nella diagnosi del dolore neuropatico?CAN WE QUANTIFY ALL THE ASPECTS? Habituation phenomena

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


Visual vs verbal vs numerical scales are they equivalent different compliance
VISUAL vs VERBAL vs NUMERICAL SCALES: applicati nella diagnosi del dolore neuropatico?ARE THEY EQUIVALENT? Different compliance

MJ Hjermstad et al.

JPainSymptomManage 2011, 41 (6): 1073-93 (1)


Visual vs verbal vs numerical scales are they equivalent differences in patients preferences
VISUAL vs VERBAL vs NUMERICAL SCALES: applicati nella diagnosi del dolore neuropatico?ARE THEY EQUIVALENT? Differences in patients preferences

JPainSymptomManage 2011, 41 (6): 1073-93 (2)


Visual vs verbal vs numerical scales are they equivalent no agreement about the recommendations
VISUAL vs VERBAL vs NUMERICAL SCALES: applicati nella diagnosi del dolore neuropatico?ARE THEY EQUIVALENT? No agreement about the recommendations

JPainSymptomManage 2011, 41 (6): 1073-93 (3)


The pharmacological treatment the np scales cover all the aspects of the clinical response
THE PHARMACOLOGICAL TREATMENT: applicati nella diagnosi del dolore neuropatico?THE NP SCALES COVER ALL THE ASPECTS OF THE CLINICAL RESPONSE?

N Attal et al.

European Journal of Neurology 2010, 17: 1113-1123


The nociceptive pain are the same scales useful or not a poorly investigated issue
THE NOCICEPTIVE PAIN: applicati nella diagnosi del dolore neuropatico?ARE THE SAME SCALES USEFUL OR NOT? A poorly investigated issue

GA Hawker et al.

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


Incontro nazionale neurofisiologia nuove strategie
THE NOCICEPTIVE PAIN: applicati nella diagnosi del dolore neuropatico?ARE THE SAME SCALES USEFUL OR NOT? MPQ is useful to discriminate different type of pain,but…..

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


Assessing np in clinical trials the scales are enough the role of quantitative sensory testing
ASSESSING NP IN CLINICAL TRIALS: applicati nella diagnosi del dolore neuropatico?THE SCALES ARE ENOUGH? The role of Quantitative Sensory Testing

N Attal et al.

What is the relevance of symptom oriented classifications of NP?

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


Assessing np in clinical trials the scales are enough different drugs and different effects
ASSESSING NP IN CLINICAL TRIALS: applicati nella diagnosi del dolore neuropatico?THE SCALES ARE ENOUGH? Different drugs and different effects

Assessing symptoms and signs in clinical trials of NP

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


Assessing np in clinical trials the scales are enough qst is fundamental in therapeutical trial
ASSESSING NP IN CLINICAL TRIALS: applicati nella diagnosi del dolore neuropatico?THE SCALES ARE ENOUGH? QST is fundamental in therapeutical trial

Recommendations on sensory profiling to increase therapeutic prediction

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


Diagnosis and assessment of np the main questions
DIAGNOSIS AND ASSESSMENT OF NP: applicati nella diagnosi del dolore neuropatico?THE MAIN QUESTIONS

D Bouhassira, N Attal

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

Pain 2011, 152:74-83 (1)


Diagnosis and assessment of np the main questions1

Description and discriminant properties of the screening tools

DIAGNOSIS AND ASSESSMENT OF NP:THE MAIN QUESTIONS

Pain 2011, 152:74-83 (2)


Diagnosis and assessment of np the main questions2
DIAGNOSIS AND ASSESSMENT OF NP: toolsTHE MAIN QUESTIONS

Conditions of use and limitations of the screening tools

Pain 2011, 152:74-83 (3)


Diagnosis and assessment of np the main questions3
DIAGNOSIS AND ASSESSMENT OF NP: toolsTHE MAIN QUESTIONS

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

The Neuropathic pain Scale

Pain 2011, 152:74-83 (4)


Diagnosis and assessment of np the main questions4
DIAGNOSIS AND ASSESSMENT OF NP: toolsTHE MAIN QUESTIONS

Other questionnaires

Pain 2011, 152:74-83 (5)


Diagnosis and assessment of np the main questions5
DIAGNOSIS AND ASSESSMENT OF NP: toolsTHE MAIN QUESTIONS

Are neuropathic pain symptoms or dimensions related to the etiology?

Pain 2011, 152:74-83 (6)


Diagnosis and assessment of np the main questions6
DIAGNOSIS AND ASSESSMENT OF NP: toolsTHE MAIN QUESTIONS

Do pain symptoms tell us something about the pathophysiological mechanisms?

Pain 2011, 152:74-83 (7)


Np assessment questionnaire a role in the guidelines
NP ASSESSMENT QUESTIONNAIRE: toolsA ROLE IN THE GUIDELINES?

G Cruccu et al.

Screening and assessment tools

European Journal of Neurology 2010, 17:1010-1018


Dn4 questionnaire aetiology is relevant
DN4 QUESTIONNAIRE: AETIOLOGY IS RELEVANT? tools

N Attal et al.

JPain 2011, 12 (10):1080-1087 (1)


Dn4 questionnaire aetiology is relevant1
DN4 QUESTIONNAIRE: AETIOLOGY IS RELEVANT? tools

JPain 2011, 12 (10):1080-1087 (2)


Screening tools in np are there limitations in clinical practice and research
SCREENING TOOLS IN NP: toolsARE THERE LIMITATIONS IN CLINICAL PRACTICE AND RESEARCH?

Role of screening tools in clinical practice and research

Bridging the gap between definition and diagnosis

Pain 2007, 127:199-203


Np the guidelines are applied in clinical practice
NP: THE GUIDELINES ARE APPLIED IN CLINICAL PRACTICE? tools

G Cruccu, N Attal

Pain 2012, 153:740-741


Nps are able to identify the subgroups
NPS: ARE ABLE TO IDENTIFY THE SUBGROUPS? tools

SG Bradley

Neurology 1997, 48:332-338


Conclusions
CONCLUSIONS tools

NP scales have limits, but…

We 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 can we quantify all the aspects 7
DIMENSIONS OF PAIN EXPERIENCE AND LANGUAGE OF PAIN: toolsCAN WE QUANTIFY ALL THE ASPECTS? (7)

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


Visual vs verbal vs numerical scales are they equivalent 2
VISUAL vs VERBAL vs NUMERICAL SCALES: toolsARE THEY EQUIVALENT? (2)

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


Visual vs verbal vs numerical scales are they equivalent 3
VISUAL vs VERBAL vs NUMERICAL SCALES: toolsARE THEY EQUIVALENT? (3)

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


Visual vs verbal vs numerical scales are they equivalent 6
VISUAL vs VERBAL vs NUMERICAL SCALES: toolsARE THEY EQUIVALENT? (6)

Conclusions

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


The nociceptive pain are the same scales useful or not 2
THE NOCICEPTIVE PAIN: toolsARE THE SAME SCALES USEFUL OR NOT? (2)

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


The nociceptive pain are the same scales useful or not 4
THE NOCICEPTIVE PAIN: toolsARE THE SAME SCALES USEFUL OR NOT? (4)

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


The nociceptive pain are the same scales useful or not 5
THE NOCICEPTIVE PAIN: toolsARE THE SAME SCALES USEFUL OR NOT? (5)

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


The nociceptive pain are the same scales useful or not 6
THE NOCICEPTIVE PAIN: toolsARE THE SAME SCALES USEFUL OR NOT? (6)

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


Screening tools in np are there limitations in clinical practice and research 1

MI Bennett et al. tools

SCREENING TOOLS IN NP: ARE THERE LIMITATIONS IN CLINICAL PRACTICE AND RESEARCH? (1)

Limitations

Independent validation

Pain 2007, 127:199-203


Npsi from experimental to clinical pain
NPSI: FROM EXPERIMENTAL TO CLINICAL PAIN tools

D Bouhassira

Pain 2004, 108:248-257