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Robert D. Vining, DC
Is There an Efficient Tool to Help Identify Neuropathic Pain?
J Amer Chiropr Assoc 2012 Nov-Dec;49(6):7-9
|Abstract: Dr. Vining looks at how DCs can find expert help when a patient’s symptoms suggest the possibility of pain from more than one condition.|
Abstract: In this column, educators and researchers from Palmer College of Chiropractic explore questions of clinical interest to JACA readers. These authors will offer tips on weighing and making good use of evidence as part of the everyday practice of chiropractic.
A patient presents with radiating pain
An evidence-based consideration:
You decide to read the following article:
Diagnostic tool comparison:
Walsh and colleagues recruited 45 patients referred to hospitals by general practitioners for evaluation and management of low-back pain. Patients completed the S-LANSS and self-report section of the DN4. An independent examiner (blind to the self-report answers) performed and answered the 2 DN4 examination questions. Another independent examiner scored the questionnaires and determined the presence or absence of neuropathic pain based on cutoff scores of 12 (S-LANSS) and 4 (DN4). The authors then compared the neuropathic vs. nociceptive pain classification of both tools.
Results and limitations
Despite less than perfect agreement between the S-LANSS and the DN4, both identify approximately 80 percent of patients with neuropathic pain. Current diagnostic criteria for neuropathic pain are based on sound theoretical principles and physiological evidence (construct validity). However, no objective test is available to confirm a diagnosis. Therefore, the reference standard used to validate these tools is expert clinician diagnosis. Expert diagnosis tends toward error and inconsistent interpretation, leaving it somewhat lacking as a reference standard. Nevertheless, it is the best reference standard currently available.
Is this information useful for me?
1. Bouhassira D, Attal N. Diagnosis and assessment of neuropathic pain: The saga of clinical tools. Pain 2011 Mar;152(3). Suppl):S74-S83.5
2. Bennett MI, Attal N, Backonja MM, Baron R, Bouhassira D, Freynhagen R, Scholz J, Tolle TR, Wittchen HU, Jensen TS. Using screening tools to identify neuropathic pain. Pain 2007 Feb;127(3):199-203.6
Both articles describe and compare 5 validated screening tools and their application in both clinical and research settings. They include information on diagnostic sensitivity, test questions, scoring, key definitions, and use in daily practice. They also provide examples of cases for which these tools were not designed, such as patients with widespread or multiple pain locations (e.g., fibromyalgia).
Given that these screening tools take only a few moments to complete and incorporate into an examination, and that they help differentiate nociceptive from neuropathic pain in approximately 80 percent of appropriate cases, your question may now change to “Which screening tool should I use to aid my differential diagnosis?” The 2 articles found in your second PubMed search5,6will very likely provide the information you need for this evidence-informed decision.
Sometimes, as described here, searching for an answer to 1 question leads you along a “literature trail.” That “trail” may guide you along a path you did not anticipate and toward a different or more appropriate question. Regardless of whether you choose to incorporate a neuropathic screening tool into your practice, your search should arm you with more information and strengthen your evidence-based decisions.
Dr. Vining is assistant professor and senior research clinician at the Palmer Center for Chiropractic Research, Palmer College of Chiropractic, Davenport, Iowa.
1. Walsh J, Rabey MI, Hall TM. Agreement and correlation between the self-report Leeds assessment of neuropathic symptoms and signs and Douleur Neuropathique 4 Questions neuropathic pain screening tools in subjects with low back-related leg pain. J Manipulative Physiol Ther 2012 Mar;35(3):196-202.
2. Bennett MI, Smith BH, Torrance N, Potter J. The S-LANSS score for identifying pain of predominantly neuropathic origin: validation for use in clinical and postal research. J Pain 2005 Mar;6(3):149-58.
3. Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, Cunin G, Fermanian J, Ginies P, Grun-Overdyking A, Jafari-Schluep H, Lanteri-Minet M, Laurent B, Mick G, Serrie A, Valade D, Vicaut E. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain 2005 Mar;114(1-2):29-36.
4. Bennett M. The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs. Pain 2001 May;92(1-2):147-57.
5. Bouhassira D, Attal N. Diagnosis and assessment of neuropathic pain: the saga of clinical tools. Pain 2011 Mar;152(3 Suppl):S74-S83.
6. Bennett MI, Attal N, Backonja MM, Baron R, Bouhassira D, Freynhagen R, Scholz J, Tolle TR, Wittchen HU, Jensen TS. Using screening tools to identify neuropathic pain. Pain 2007 Feb;127(3):199-203.