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Journal ArticleDOI

A novel tool for the assessment of pain: validation in low back pain.

TL;DR: Joachim Scholz and colleagues develop and validate an assessment tool that distinguishes between radicular and axial low back pain.
Abstract: Background Adequate pain assessment is critical for evaluating the efficacy of analgesic treatment in clinical practice and during the development of new therapies. Yet the currently used scores of global pain intensity fail to reflect the diversity of pain manifestations and the complexity of underlying biological mechanisms. We have developed a tool for a standardized assessment of pain-related symptoms and signs that differentiates pain phenotypes independent of etiology. Methods and Findings Using a structured interview (16 questions) and a standardized bedside examination (23 tests), we prospectively assessed symptoms and signs in 130 patients with peripheral neuropathic pain caused by diabetic polyneuropathy, postherpetic neuralgia, or radicular low back pain (LBP), and in 57 patients with non-neuropathic (axial) LBP. A hierarchical cluster analysis revealed distinct association patterns of symptoms and signs (pain subtypes) that characterized six subgroups of patients with neuropathic pain and two subgroups of patients with non-neuropathic pain. Using a classification tree analysis, we identified the most discriminatory assessment items for the identification of pain subtypes. We combined these six interview questions and ten physical tests in a pain assessment tool that we named Standardized Evaluation of Pain (StEP). We validated StEP for the distinction between radicular and axial LBP in an independent group of 137 patients. StEP identified patients with radicular pain with high sensitivity (92%; 95% confidence interval [CI] 83%–97%) and specificity (97%; 95% CI 89%–100%). The diagnostic accuracy of StEP exceeded that of a dedicated screening tool for neuropathic pain and spinal magnetic resonance imaging. In addition, we were able to reproduce subtypes of radicular and axial LBP, underscoring the utility of StEP for discerning distinct constellations of symptoms and signs. Conclusions We present a novel method of identifying pain subtypes that we believe reflect underlying pain mechanisms. We demonstrate that this new approach to pain assessment helps separate radicular from axial back pain. Beyond diagnostic utility, a standardized differentiation of pain subtypes that is independent of disease etiology may offer a unique opportunity to improve targeted analgesic treatment.

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Journal ArticleDOI
01 Mar 2011-Pain
TL;DR: Diagnostic criteria to establish the presence of central sensitization in patients will greatly assist the phenotyping of patients for choosing treatments that produce analgesia by normalizing hyperexcitable central neural activity.
Abstract: Nociceptor inputs can trigger a prolonged but reversible increase in the excitability and synaptic efficacy of neurons in central nociceptive pathways, the phenomenon of central sensitization. Central sensitization manifests as pain hypersensitivity, particularly dynamic tactile allodynia, secondary punctate or pressure hyperalgesia, aftersensations, and enhanced temporal summation. It can be readily and rapidly elicited in human volunteers by diverse experimental noxious conditioning stimuli to skin, muscles or viscera, and in addition to producing pain hypersensitivity, results in secondary changes in brain activity that can be detected by electrophysiological or imaging techniques. Studies in clinical cohorts reveal changes in pain sensitivity that have been interpreted as revealing an important contribution of central sensitization to the pain phenotype in patients with fibromyalgia, osteoarthritis, musculoskeletal disorders with generalized pain hypersensitivity, headache, temporomandibular joint disorders, dental pain, neuropathic pain, visceral pain hypersensitivity disorders and post-surgical pain. The comorbidity of those pain hypersensitivity syndromes that present in the absence of inflammation or a neural lesion, their similar pattern of clinical presentation and response to centrally acting analgesics, may reflect a commonality of central sensitization to their pathophysiology. An important question that still needs to be determined is whether there are individuals with a higher inherited propensity for developing central sensitization than others, and if so, whether this conveys an increased risk in both developing conditions with pain hypersensitivity, and their chronification. Diagnostic criteria to establish the presence of central sensitization in patients will greatly assist the phenotyping of patients for choosing treatments that produce analgesia by normalizing hyperexcitable central neural activity. We have certainly come a long way since the first discovery of activity-dependent synaptic plasticity in the spinal cord and the revelation that it occurs and produces pain hypersensitivity in patients. Nevertheless, discovering the genetic and environmental contributors to and objective biomarkers of central sensitization will be highly beneficial, as will additional treatment options to prevent or reduce this prevalent and promiscuous form of pain plasticity.

3,331 citations


Cites background from "A novel tool for the assessment of ..."

  • ...horts to capture exactly what changes in sensitivity occur, where and when [9,11,55,86,93,188,197]....

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Journal ArticleDOI
TL;DR: A better understanding of neuropathic pain and of the translation of pathophysiological mechanisms into sensory signs will lead to a more effective and specific mechanism-based treatment approach.
Abstract: Summary Neuropathic pain develops as a result of lesions or disease affecting the somatosensory nervous system either in the periphery or centrally. Examples of neuropathic pain include painful polyneuropathy, postherpetic neuralgia, trigeminal neuralgia, and post-stroke pain. Clinically, neuropathic pain is characterised by spontaneous ongoing or shooting pain and evoked amplified pain responses after noxious or non-noxious stimuli. Methods such as questionnaires for screening and assessment focus on the presence and quality of neuropathic pain. Basic research is enabling the identification of different pathophysiological mechanisms, and clinical assessment of symptoms and signs can help to determine which mechanisms are involved in specific neuropathic pain disorders. Management of neuropathic pain requires an interdisciplinary approach, centred around pharmacological treatment. A better understanding of neuropathic pain and, in particular, of the translation of pathophysiological mechanisms into sensory signs will lead to a more effective and specific mechanism-based treatment approach.

1,303 citations

Journal ArticleDOI
01 Mar 2010
TL;DR: A review of the evidence-based guidelines for the pharmacological treatment of neuropathic pain can be found in this article, where botulinum toxin, high-concentration capsaicin patch, lacosamide, selective serotonin reuptake inhibitors, and combination therapies are presented.
Abstract: The Neuropathic Pain Special Interest Group of the International Association for the Study of Pain recently sponsored the development of evidence-based guidelines for the pharmacological treatment of neuropathic pain. Tricyclic antidepressants, dual reuptake inhibitors of serotonin and norepinephrine, calcium channel α2-δ ligands (ie, gabapentin and pregabalin), and topical lidocaine were recommended as first-line treatment options on the basis of the results of randomized clinical trials. Opioid analgesics and tramadol were recommended as second-line treatments that can be considered for first-line use in certain clinical circumstances. Results of several recent clinical trials have become available since the development of these guidelines. These studies have examined botulinum toxin, high-concentration capsaicin patch, lacosamide, selective serotonin reuptake inhibitors, and combination therapies in various neuropathic pain conditions. The increasing number of negative clinical trials of pharmacological treatments for neuropathic pain and ambiguities in the interpretation of these negative trials must also be considered in developing treatment guidelines. The objectives of the current article are to review the Neuropathic Pain Special Interest Group guidelines for the pharmacological management of neuropathic pain and to provide a brief overview of these recent studies.

1,066 citations

Journal ArticleDOI
01 Sep 2010-Pain
TL;DR: Somatosensory profiles with different combinations of loss and gain are shared across the major neuropathic pain syndromes, including thermal and mechanical hyperalgesias, which were most frequent in complex regional pain syndrome and peripheral nerve injury, allodynia in postherpetic neuralgia.
Abstract: Neuropathic pain is accompanied by both positive and negative sensory signs. To explore the spectrum of sensory abnormalities, 1236 patients with a clinical diagnosis of neuropathic pain were assessed by quantitative sensory testing (QST) following the protocol of DFNS (German Research Network on Neuropathic Pain), using both thermal and mechanical nociceptive as well as non-nociceptive stimuli. Data distributions showed a systematic shift to hyperalgesia for nociceptive, and to hypoesthesia for non-nociceptive parameters. Across all parameters, 92% of the patients presented at least one abnormality. Thermosensory or mechanical hypoesthesia (up to 41%) was more frequent than hypoalgesia (up to 18% for mechanical stimuli). Mechanical hyperalgesias occurred more often (blunt pressure: 36%, pinprick: 29%) than thermal hyperalgesias (cold: 19%, heat: 24%), dynamic mechanical allodynia (20%), paradoxical heat sensations (18%) or enhanced wind-up (13%). Hyperesthesia was less than 5%. Every single sensory abnormality occurred in each neurological syndrome, but with different frequencies: thermal and mechanical hyperalgesias were most frequent in complex regional pain syndrome and peripheral nerve injury, allodynia in postherpetic neuralgia. In postherpetic neuralgia and in central pain, subgroups showed either mechanical hyperalgesia or mechanical hypoalgesia. The most frequent combinations of gain and loss were mixed thermal/mechanical loss without hyperalgesia (central pain and polyneuropathy), mixed loss with mechanical hyperalgesia in peripheral neuropathies, mechanical hyperalgesia without any loss in trigeminal neuralgia. Thus, somatosensory profiles with different combinations of loss and gain are shared across the major neuropathic pain syndromes. The characterization of underlying mechanisms will be needed to make a mechanism-based classification feasible.

842 citations


Cites background or result from "A novel tool for the assessment of ..."

  • ...nerve lesion induced by virus infection or by diabetes), is the best approach or whether it might be preferable to classify neuropathic pain conditions on the basis of symptoms and signs [27,46,50] or of patterns of somatosensory abnormalities and the likely underlying mechanisms [5,6,12,54]....

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  • ...In accordance with other trials [50] negative sensory signs were predominantly found in non-nociceptive parameters, with similar incidence for functions mediated by small fibers and spinothalamic tract neurons (CDT 40....

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Journal ArticleDOI
23 Feb 2012-Neuron
TL;DR: The pain phenotype can serve as a window on underlying pathophysiological neural mechanisms and as a guide for developing personalized pain medicine.

680 citations


Cites background from "A novel tool for the assessment of ..."

  • ...Patient reported outcomes, as well as quantitative sensory testing, or a combination of both, are beginning to be used to analyze sensory profiles in neuropathic pain patients and distinct subgroups of patients can be detected who are characterized by different specific sensory profiles (Baron et al., 2009; Bouhassira et al., 2005; Scholz et al., 2009)....

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  • ...Because of their mechanistic diversity and different manifestations, these processes produce a complex profile or constellation of positive and negative sensory symptoms and signs, a “pain fingerprint” (Baron et al., 2009; Mahn et al., 2011; Scholz et al., 2009)....

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  • ...Because of their mechanistic diversity and different manifestations, these processes produce a complex profile or constellation of positive and negative sensory symptoms and signs, a ‘‘pain fingerprint’’ (Baron et al., 2009; Mahn et al., 2011; Scholz et al., 2009)....

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  • ...…testing, or a combination of both, are beginning to be used to analyze sensory profiles in neuropathic pain patients and distinct subgroups of patients can be detected who are characterized by different specific sensory profiles (Baron et al., 2009; Bouhassira et al., 2005; Scholz et al., 2009)....

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References
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Journal ArticleDOI
TL;DR: In this paper, a procedure for forming hierarchical groups of mutually exclusive subsets, each of which has members that are maximally similar with respect to specified characteristics, is suggested for use in large-scale (n > 100) studies when a precise optimal solution for a specified number of groups is not practical.
Abstract: A procedure for forming hierarchical groups of mutually exclusive subsets, each of which has members that are maximally similar with respect to specified characteristics, is suggested for use in large-scale (n > 100) studies when a precise optimal solution for a specified number of groups is not practical. Given n sets, this procedure permits their reduction to n − 1 mutually exclusive sets by considering the union of all possible n(n − 1)/2 pairs and selecting a union having a maximal value for the functional relation, or objective function, that reflects the criterion chosen by the investigator. By repeating this process until only one group remains, the complete hierarchical structure and a quantitative estimate of the loss associated with each stage in the grouping can be obtained. A general flowchart helpful in computer programming and a numerical example are included.

17,405 citations


"A novel tool for the assessment of ..." refers methods in this paper

  • ...We applied Ward’s method [23] to perform a hierarchical cluster analysis on the distance matrix....

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Journal ArticleDOI
TL;DR: A nonparametric approach to the analysis of areas under correlated ROC curves is presented, by using the theory on generalized U-statistics to generate an estimated covariance matrix.
Abstract: Methods of evaluating and comparing the performance of diagnostic tests are of increasing importance as new tests are developed and marketed. When a test is based on an observed variable that lies on a continuous or graded scale, an assessment of the overall value of the test can be made through the use of a receiver operating characteristic (ROC) curve. The curve is constructed by varying the cutpoint used to determine which values of the observed variable will be considered abnormal and then plotting the resulting sensitivities against the corresponding false positive rates. When two or more empirical curves are constructed based on tests performed on the same individuals, statistical analysis on differences between curves must take into account the correlated nature of the data. This paper presents a nonparametric approach to the analysis of areas under correlated ROC curves, by using the theory on generalized U-statistics to generate an estimated covariance matrix.

16,496 citations


"A novel tool for the assessment of ..." refers methods in this paper

  • ...To compare the AUCs of ROC curves, we generated an estimated covariance matrix based on a nonparametric approach using the theory on generalized Ustatistics [30]....

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Journal ArticleDOI
Ronald Melzack1
01 Sep 1975-Pain
TL;DR: The McGill Pain Questionnaire as discussed by the authors consists of three major classes of word descriptors (sensory, affective and evaluative) that are used by patients to specify subjective pain experience.
Abstract: The McGill Pain Questionnaire consists primarily of 3 major classes of word descriptors--sensory, affective and evaluative--that are used by patients to specify subjective pain experience. It also contains an intensity scale and other items to determine the properties of pain experience. The questionnaire was designed to provide quantitative measures of clinical pain that can be treated statistically. This paper describes the procedures for administration of the questionnaire and the various measures that can be derived from it. The 3 major measures are: (1) the pain rating index, based on two types of numerical values that can be assigned to each word descriptor, (2) the number of words chosen; and (3) the present pain intensity based on a 1-5 intensity scale. Correlation coefficients among these measures, based on data obtained with 297 patients suffering several kinds of pain, are presented. In addition, an experimental study which utilized the questionnaire is analyzed in order to describe the nature of the information that is obtained. The data, taken together, indicate that the McGill Pain Questionnaire provides quantitative information that can be treated statistically, and is sufficiently sensitive to detect differences among different methods to relieve pain.

6,007 citations

Journal Article
30 Aug 1975-Brain
TL;DR: The data indicate that the McGill Pain Questionnaire provides quantitative information that can be treated statistically, and is sufficiently sensitive to detect differences among different methods to relieve pain.
Abstract: The McGill Pain Questionnaire consists primarily of 3 major classes of word descriptors--sensory, affective and evaluative--that are used by patients to specify subjective pain experience. It also contains an intensity scale and other items to determine the properties of pain experience. The questionnaire was designed to provide quantitative measures of clinical pain that can be treated statistically. This paper describes the procedures for administration of the questionnaire and the various measures that can be derived from it. The 3 major measures are: (1) the pain rating index, based on two types of numerical values that can be assigned to each word descriptor, (2) the number of words chosen; and (3) the present pain intensity based on a 1-5 intensity scale. Correlation coefficients among these measures, based on data obtained with 297 patients suffering several kinds of pain, are presented. In addition, an experimental study which utilized the questionnaire is analyzed in order to describe the nature of the information that is obtained. The data, taken together, indicate that the McGill Pain Questionnaire provides quantitative information that can be treated statistically, and is sufficiently sensitive to detect differences among different methods to relieve pain.

5,944 citations

Journal ArticleDOI
TL;DR: A general coefficient measuring the similarity between two sampling units is defined and the matrix of similarities between all pairs of sample units is shown to be positive semidefinite.
Abstract: A general coefficient measuring the similarity between two sampling units is defined. The matrix of similarities between all pairs of sample units is shown to be positive semidefinite (except possibly when there are missing values). This is important for the multidimensional Euclidean representation of the sample and also establishes some inequalities amongst the similarities relating three individuals. The definition is extended to cope with a hierarchy of characters.

4,204 citations


"A novel tool for the assessment of ..." refers methods in this paper

  • ...org/), we calculated a distance matrix based on Gower’s general dissimilarity coefficient [22]....

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