Outcome Measures

in Neuropathic Pain

Suroto
Dept of Neurology, Fac of Medicine
Sebelas Maret University
www.suroto-sr.com
 +-

Pain and Pain Measurement

• Detecting Neuropathic Pain Component
• Neuropathic Pain and Outcome
Measurement

2
 Outcomes Measurement
 Outcomes measurement: systematic collection and analysis
of information - evaluate the efficacy of an intervention.

 In clinical settings: collected before and after an

intervention.

 The best methode: psychometric scales and quality of life

measures.

3
 The ideal pain assessment tool
would have the following attributes

• Sensitive and free from bias;

• Immediate information about accuracy and
reliability;
• Distinguishes between pain, unpleasantness
and emotion;
• Assesses experimental and clinical pain;
• Absolute rather than relative scales;
• Estimates confidence of predictions.
4
5
 Unidimensional Scale

6
 Unidimensional vs
Multidimensional Scale
• In many situations, one-item instrument is not sufficient to
capture pain or quality of life. Many comprehensive measures
of pain exist.
• Measure several dimensions of pain - with differing
combinations of pain intensity, quality, affect, interference
with functioning, and effects on general quality of life.
• By comprehensive measure of pain  managing the
commonly observed lack of association between pain
intensity and disability.

7
 McGill Pain Questionnaire (MPQ)

• A self-report measure of pain in general.

• Melzack, 1975.
• Assesses both the quality and intensity of pain.
• Composed of 78 words, of which respondents choose
• Pain descriptors = 42; Affective components of pain = 14;
Evaluation of pain = 5; Miscellaneous = 17).
• Scores range : 0 (no pain) to 78 (severe pain).
• Shows the complexity of pain.

8
9
10
 • Pain and Pain Measurement
Detecting Neuropathic Pain Component
• Neuropathic Pain and Outcome
Measurement

11
Flow chart of grading system for neuropathic pain

12 PAIN (2010), doi:10.1016

13
 LANSS:
Leeds Assessment of Neuropathic Symptoms and
Signs pain scale.

• Since its publication in 2001, the LANSS Pain Scale has been used
widely
• 7-item tool for identifying the presence of symptoms (5 items) or
clinical signs (2 items).
• Each item is a binary response (yes or no)
• A modified S-LANSS (self-report LANSS) can be used by patients
in the absence of a clinician.
• Both LANSS and S-LANS S  total score of 24.
• Score of 12 or more  suffering from NP to some degree.

14
15
 painDETECT questionnaire (PD-Q)
• Fast and uncomplicated way to ascertain the component of NP in
'total pain‘.
• Initially developed and validated in pts with back pain; but has
shown applicability also to pts with other types of NP.
• Useful for identifying different sensory profiles of NP when a NP
condition (e.g. PDN or PHN) has already been diagnosed
• Self-report questionnaire with 9 items:7 weighted sensory
descriptor items and 2 items relating to the spatial (radiating) and
temporal characteristics of the individual pain pattern.
• For screening purposes  cut-off scores ≤ 12 (a neuropathic
component is unlikely) and ≥ 19 (a neuropathic component is likely.

16
17
18
19
20
 DN4 Questionnaire
INTERVIEW OF THE PATIENT
Question 1: Does the pain have one or more of the following characteristics?
1 – Burning
2 – Painful cold
3 – Electric shocks
Question 2: Is the pain associated with one of more of the following symptoms in the
same area?
4 – Tingling
5 – Pins and needles
6 – Numbness
7 – Itching
EXAMINATION OF THE PATIENT
Question 3: Is the pain located in an area where the physical examination may reveal one
or more of the following characteristics?
8 – Hypoesthesia to touch
9 – Hypoesthesia to prick
Question 4: In the painful area, can the pain be caused or increased by:
10 – Brushing
The total score is calculated as the sum of the 10 items and the cut-
off value for the diagnosis of neuropathic pain is a total score of 4/10.
21 Bouhassira D, Attal N, Alchaar H, et al. "Comparison of pain syndromes associated with nervous or somatic
lesions and development of a new neuropathic pain diagnostic questionnaire (DN4)." Pain 114.1-2 (2005): 29-36.
22
 Sensitivity and Specificity of
Neuropathic Pain Screening Tools
Name Description Sensitivity* Specificity*
Interview-based
NPQ 10 sensory-related items + 2 affect items 66% 74%
ID-Pain 5 sensory items + 1 pain location NR NR

painDETECT 7 sensory items + 2 spatial characteristics items 85% 80%

Interview + physical tests

LANSS 5 symptom items + 2 clinical exam items 82–91% 80–94%

DN4 7 symptom items + 3 clinical exam items 83% 90%

Tests incorporating both interview questions and physical tests have higher
sensitivity and specificity than tools that rely only on interview questions
*Compared with clinical diagnosis
DN4 = Douleur neuropathic en 4 questions; LANSS = Leeds Assessment of Neuropathic Symptoms and Signs;
NPQ = Neuropathic Pain Questionnaire; NR = not reported
Bennett MI et al. Pain 2007; 127(3):199-203.
 • Pain and Pain Measurement
• Detecting Neuropathic Pain Component
Neuropathic Pain and Outcome
Measurement

24
 Outcome Measuring tool of NP

• NPS: Neuropathic Pain Scale

• NPSI: Neuropathic Pain Symptom Inventory

• PQAS: Pain Quality Assessment Scale

25
 NPS (Neuropathic Pain Scale)

• Only for use in patients who have already been diagnosed

with NP.
• Should not be used to determine IF a patient's pain is
secondary to neuropathy.
• Scores are based on patient responses to questions about
pain intensity: 0 indicates no pain; 10 indicates the most pain
imaginable.
• Comprehensive and wise method for assessing NP and may be
particularly useful for assessing response to therapies.

26
27
28
29
 Sensory profile and its impact on quality of life in
patients with painful diabetic polyneuropathy.

J Neurosci Rural Pract. 2013 Jul-Sep; 4(3): 267–270.

30
 NPS vs LANSS

31
 NPS vs PQAS

• The Neuropathic Pain Scale (NPS) has the most empirical

support as a measure of treatment outcome.

• A new measure that includes the NPS items (the PQAS: Pain
Quality Assessment Scale) will likely prove to be even more
useful, because it includes pain descriptors common to people
with neuropathic and other chronic pain conditions not included
on the NPS.

32
 PQAS
• The specific items added: assessed tender, numb, electrical,
tingling, radiating, throbbing, aching, shooting, cramping, and
heavy pain qualities.
• Added: 3 temporal classifications of pain designed to assess:
intermittent, variable, and constant
• Because the resulting questionnaire could be used to assess
pain both NP and non NP, the word neuropathic was removed
 20-item measure the Pain Quality Assessment Scale (PQAS)

The Journal of Pain, Vol 7, No 11 (November), 2006: pp 823-83

33
34
35
36
37
 The PQAS in Carpal Tunnel Syndrome

38 The Journal of Pain, Vol 7, No 11 (November), 2006: pp 823-83

 Summary
 Outcomes measurement: systematic collection and analysis of
information - evaluate the efficacy of an intervention
 In many situations, one-item instrument is not sufficient to
capture pain or quality of life. Many comprehensive measures
of pain exist
 Some scales used to determine IF a patient's pain is secondary
to neuropathy: NPQ, ID- pain, painDetect, LANSS, DN4.
 The Neuropathic Pain Scale (NPS) has the most empirical
support as a measure of treatment outcome, in NP
 Pain Quality Assessment Scale (PQAS) includes pain
descriptors common to people with neuropathic and other
chronic pain conditions
39