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Institute
- Fakultät WiSo (2145) (remove)
Background and aims
In 2008, the International Association for the Study of Pain Special Interest Group on Neuropathic Pain (NeuPSIG) proposed a clinical grading system to help identify patients with neuropathic pain (NeP). We previously applied this classification system, along with two NeP screening tools, the painDETECT (PD-Q) and Leeds Assessment of Neuropathic Symptoms and Signs pain scale (LANSS), to identify NeP in patients with neck/upper limb pain. Both screening tools failed to identify a large proportion of patients with clinically classified NeP, however a limitation of our study was the use of a single clinician performing the NeP classification. In 2016, the NeuPSIG grading system was updated with the aim of improving its clinical utility. We were interested in field testing of the revised grading system, in particular in the application of the grading system and the agreement of interpretation of clinical findings. The primary aim of the current study was to explore the application of the NeuPSIG revised grading system based on patient records and to establish the inter-rater agreement of detecting NeP. A secondary aim was to investigate the level of agreement in detecting NeP between the revised NeuPSIG grading system and the LANSS and PD-Q.
Methods
In this retrospective study, two expert clinicians (Specialist Pain Medicine Physician and Advanced Scope Physiotherapist) independently reviewed 152 patient case notes and classified them according to the revised grading system. The consensus of the expert clinicians’ clinical classification was used as “gold standard” to determine the diagnostic accuracy of the two NeP screening tools.
Results
The two clinicians agreed in classifying 117 out of 152 patients (ICC 0.794, 95% CI 0.716–850; κ 0.62, 95% CI 0.50–0.73), yielding a 77% agreement. Compared to the clinicians’ consensus, both LANSS and PD-Q demonstrated limited diagnostic accuracy in detecting NeP (LANSS sensitivity 24%, specificity 97%; PD-Q sensitivity 53%, specificity 67%).
Conclusions
The application of the revised NeP grading system was feasible in our retrospective analysis of patients with neck/upper limb pain. High inter-rater percentage agreement was demonstrated. The hierarchical order of classification may lead to false negative classification. We propose that in the absence of sensory changes or diagnostic tests in patients with neck/upper limb pain, classification of NeP may be further improved using a cluster of clinical findings that confirm a relevant nerve lesion/disease, such as reflex and motor changes. The diagnostic accuracy of LANSS and PD-Q in identifying NeP in patients with neck/upper limb pain remains limited. Clinical judgment remains crucial to diagnosing NeP in the clinical practice.
Implications
Our observations suggest that in view of the heterogeneity in patients with neck/upper limb pain, a considerable amount of expertise is required to interpret the revised grading system. While the application was feasible in our clinical setting, it is unclear if this will be feasible to apply in primary health care settings where early recognition and timely intervention is often most needed. The use of LANSS and PD-Q in the identification of NeP in patients with neck/upper limb pain remains questionable.
Background: The painDETECT questionnaire (PD-Q) has been used as a tool to characterize sensory abnormalities in patients with persistent pain. This study investigated whether the self-reported sensory descriptors of patients with painful cervical radiculopathy (CxRAD) and patients with fibromyalgia (FM), as characterized by responses to verbal sensory descriptors from PD-Q (sensitivity to light touch, cold, heat, slight pressure, feeling of numbness in the main area of pain), were associated with the corresponding sensory parameters as demonstrated by quantitative sensory testing (QST).
Methods: Twenty-three patients with CxRAD (eight women, 46.3 ± 9.6 years) and 22 patients with FM (20 women, 46.1 ± 11.5 years) completed the PD-Q. Standardized QST of dynamic mechanical allodynia, cold and heat pain thresholds, pressure pain thresholds, mechanical and vibration detection thresholds, was recorded from the maximal pain area. Comparative QST data from 31 age-matched healthy controls (HCs; 15 women) were obtained.
Results: Patients with CxRAD demonstrated a match between their self-reported descriptors and QST parameters for all sensory parameters except for sensitivity to light touch, and these matches were statistically significant compared with HC data (p ≤ 0.006). The FM group demonstrated discrepancies between the PD-Q and QST sensory phenotypes for all sensory descriptors, indicating that the self-reported sensory descriptors did not consistently match the QST parameters (p = ≤0.017).
Conclusion: Clinicians and researchers should be cautious about relying on PD-Q as a stand-alone screening tool to determine sensory abnormalities in patients with FM.
Differentiating nociceptive and neuropathic components of clinical pain presentations matters!
(2016)
Identification of differences in clinical presentation and underlying pain mechanisms may assist the classification of patients with neck–arm pain which is important for the provision of targeted best evidence based management. The aim of this study was to: (i) assess the inter-examiner agreement in using specific systems to classify patients with cervical radiculopathy and patients with non-specific neck–arm pain associated with heightened nerve mechanosensitivity (NSNAP); (ii) assess the agreement between two clinical examiners and two clinical experts in classifying these patients, and (iii) assess the diagnostic accuracy of the two clinical examiners. Forty patients with unilateral neck–arm pain were examined by two clinicians and classified into (i) cervical radiculopathy, (ii) NSNAP, (iii) other. The classifications were compared to those made independently by two experts, based on a review of patients' clinical assessment notes. The experts' opinion was used as the reference criterion to assess the diagnostic accuracy of the clinical examiners in classifying each patient group. There was an 80% agreement between clinical examiners, and between experts and 70%–80% between clinical examiners and experts in classifying patients with cervical radiculopathy (kappa between 0.41 and 0.61). Agreement was 72.5%–80% in classifying patients with NSNAP (kappa between 0.43 and 0.52). Clinical examiners' diagnostic accuracy was high (radiculopathy: sensitivity 79%–84%; specificity 76%–81%; NSNAP: sensitivity 78%–100%; specificity 71%–81%). Compared to expert opinion, clinicians were able to identify patients with cervical radiculopathy and patients with NSNAP in 80% of cases, our data supporting the reliability of these classification systems.
Nervenschmerz ist nicht gleich Nervenschmerz. Um Patienten mit ausstrahlenden Schmerzen, bei denen die Nerven eine Rolle spielen könnten, adäquat zu therapieren, sind eine gründliche Untersuchung und ein fundiertes Clinical Reasoning unerlässlich. Nur dadurch entpuppen sich die beiden Patientinnen mit fast identischen Symptomen als sehr unterschiedlich.
Neuropathischer Schmerz
(2014)
Neuropathische Schmerzen entstehen durch eine Läsion oder Erkrankung des somatosensorischen Nervensystems. Davon sind ca. 7 – 8 % der Normalbevölkerung betroffen. Patienten mit neuropathischen Schmerzen leiden unter erheblichen Einschränkungen ihrer Lebensqualität und die daraus resultierenden staatlichen Gesundheitskosten sind extrem hoch.
Die frühe Identifikation vorhandener neuropathischer Schmerzen ist ausschlaggebend für eine gezielte Schmerztherapie und Vorbeugung einer Chronifizierung des Krankheitszustandes. Das klinische Bild ist vielfältig, und die Diagnostik kann in der klinischen Praxis eine Herausforderung darstellen.
Der Schwerpunkt dieses Artikels liegt in der Untersuchung und Diagnosestellung neuropathischer Schmerzen.
Neurotension – Gestern und Heute. Wie ist der momentane Kenntnisstand, und wie setze ich ihn um?
(2018)
Workshop: “‘Sciatica’: neuropathic or not and does it matter? Outcomes from a NeuPSIG working group”
(2023)
The identification of neuropathic pain in persons with spine-related leg pain is important as this information guides treatment and management, including self-management. The NeuPSIG neuropathic pain grading system was developed to assist clinicians and researchers in determining whether patients have neuropathic pain and the level of confidence associated with that decision. Based on clinical and laboratory examination findings, patients are classified as having no neuropathic pain, possible, probable or definite neuropathic pain. Whereas this grading system works nicely in people with systemic neuropathies where sensory findings and diagnostic tests are mostly present, its application in patients with spine-related leg pain, particular in radicular pain, can be challenging. For example, in the absence of sensory changes and MRI findings, patients with radicular pain would at best reach a classification of possible neuropathic pain according to the current neuropathic pain grading system.
In this presentation I will explain the adaptations to the neuropathic pain grading system for spine-related leg pain recommended by the NeuPSIG working group. I will demonstrate its application in clinical practice using case studies and provide clarity for how the system can be incorporated in clinical trials. This will be an interactive session with audience participation.
Background: Lumbar discectomy is considered a safe, efficacious and cost-effective treatment for selected cases of patients with leg pain associated with the presence of a disc protrusion. But despite technically successful surgery, 30 % of patients complain of persistent pain on long-term follow up. Identification of possible predictors for a negative outcome is important, in the search for appropriate pre- and/or post-operative care and prevention of persistent disability. There is some evidence in the literature that quantitative sensory testing (QST) measures may play a role in prediction of patients’ pain persistency, however, this has never been investigated in patients undergoing lumbar discectomy.
Objective: The aim of this study is to determine the predictive value of QST parameters, in combination with previously documented predictor variables such as medical/psychological/cognitive behavioural factors, in patients with lumbar radiculopathy and/or radicular pain, for predicting patients’ clinical outcome after lumbar discectomy.
Method: Participants with radiculopathy and/or radicular pain and confirmed imaging diagnosis of nerve root compression will be recruited from the elective surgery waitlist at one hospital. All participants will undergo lumbar discectomy performed by one neurosurgeon. A standardized QST protocol comprising all of the somatosensory sub-modalities that are mediated by different primary afferents (C-, Aδ-, Aβ-) will be performed prior to surgery. QST will be conducted in the patients’ main pain area and contralateral side, in the affected dermatome and at a remote control site. The presence of other predictor variables will be captured by questionnaires. Follow-up at 3 months will include QST and measurements of pain intensity, pain descriptors, functional status, health related quality of life, return to work and health care utilisation. A further 1-year follow-up will include the same measurements except QST.
Results/Conclusions: Identification of new predictor variables may assist in the development of pre-surgical screening methods and in targeted pre- and/or post-operative patient care, with the potential to improve patients’ functional status, quality of life, work capacity whilst also reducing health care costs associated with persistent disability
Objectives
To investigate differences in pressure pain thresholds (PPTs) and longitudinal mechanosensitivity of the greater occipital nerve (GON) between patients with side-dominant head and neck pain (SDHNP) and healthy controls. Evaluation of neural sensitivity is not a standard procedure in the physical examination of headache patients but may influence treatment decisions.
Methods
Two blinded investigators evaluated PPTs on two different locations bilaterally over the GON as well as the occipitalis longsitting-slump (OLSS) in subjects with SDHNP (n = 38)) and healthy controls (n = 38).
Results
Pressure pain sensitivity of the GON was lower at the occiput in patients compared to controls (p = 0.001). Differences in pressure sensitivity of the GON at the nucheal line, or between the dominant headache side and the non-dominant side were not found (p > 0.05). The OLSS showed significant higher pain intensity in SDHNP (p < 0.001). In comparison to the non-dominant side, the dominant side was significantly more sensitive (p = 0.004).
Discussion
Palpation of the GON at the occiput and the OLSS may be potentially relevant tests in SDHNP. One explanation for an increased bilateral sensitivity may be sensitization mechanisms. Future research should investigate the efficacy of neurodynamic techniques directed at the GON.