Usefulness of four commonly used neuropathic pain screening questionnaires in patients with chronic low back pain: a cross-sectional study

BACKGROUND: Recently symptoms-based screening questionnaires have gained attention for screening for a neuropathic pain component (NePC) in various chronic pain conditions. The present study assessed the usefulness of four commonly used NePC screening questionnaires including the Self-completed douleur neuropathique 4 (S-DN4), the ID Pain, the painDETECT questionnaire (PDQ), and the Self-completed Leeds Assessment of neuropathic Symptoms and Signs (S-LANSS) questionnaire in patients with chronic low back pain (CLBP) to assess the presence of NePC. METHODS: This is a single-center cross-sectional study where patients with CLBP, with or without leg pain, were included. Participants were initially screened for NePC presence by a physician according to the regular practice, and later assessed using screening questionnaires. The diagnostic accuracy of these questionnaires was compared assuming the physician-made diagnosis as the gold standard. RESULTS: A total of 215 patients with CLBP of which 164 (76.3%, 95% CI, 70.2-81.5) had a NePC were included. S-DN4, ID Pain, and PDQ have an area under the curve (AUC) > 0.8 indicating excellent discrimination. However, S-LANSS has an AUC of 0.69 (0.62-0.75), indicating low discrimination. S-DN4 has a significantly higher AUC as compared to ID Pain (d(AUC) = 0.063, P < 0.01) and S-LANSS (d(AUC) = 0.197, P < 0.01). But the AUC of S-DN4 does not significantly differ from that of PDQ (d(AUC) = 0.013, P = 0.62). CONCLUSIONS: S-DN4, ID Pain, and PDQ, but not S-LANSS, have good discriminant validity to screen for NePCs in patients with CLBP. Despite using all the tests, 20-30% of patients with an NePC were missed. Thus, these questionnaires can only be used as an initial clue in screening for NePCs, but do not replace clinical judgment.

Hindi version of short form of douleur neuropathique 4 (S-DN4) questionnaire for assessment of neuropathic pain component: a cross-cultural validation study

BACKGROUND: Pain with neuropathic characteristics is generally more severe and associated with a lower quality of life compared to nociceptive pain (NcP). Short form of the Douleur Neuropathique en 4 Questions (S-DN4) is one of the most used and reliable screening questionnaires and is reported to have good diagnostic properties. This study was aimed to cross-culturally validate the Hindi version of the S-DN4 in patients with various chronic pain conditions. METHODS: The S-DN4 is already translated into the Hindi language by Mapi Research Trust. This study assessed the psychometric properties of the Hindi version of the S-DN4 including internal consistency and test-retest reliability after 3 days' post-baseline assessment. Diagnostic performance was also assessed. RESULTS: One hundred sixty patients with chronic pain, 80 each in the neuropathic pain (NeP) present and NeP absent groups, were recruited. Patients with NeP present reported significantly higher S-DN4 scores in comparison to patients in the NeP absent group (mean (SD), 4.7 (1.7) vs. 1.8 (1.6), P < 0.01). The S-DN4 was found to have an AUC of 0.88 with adequate internal consistency (Cronbach's α = 0.80) and a test-retest reliability (ICC = 0.92) with an optimal cut-off value of 3 (Youden's index = 0.66, sensitivity and specificity of 88.7% and 77.5%). The diagnostic concordance rate between clinician diagnosis and the S-DN4 questionnaire was 83.1% (kappa = 0.66). CONCLUSIONS: Overall, the Hindi version of the S-DN4 has good internal consistency and test-retest reliability along with good diagnostic accuracy.

High Prevalence of Hypovitaminosis D in Indian Chronic Low Back Patients.

BACKGROUND: Vitamin D has a significant role to play in bone metabolism and neuromuscular function. Several researchers have indicated that Vitamin D deficiency may be possibly related to chronic musculoskeletal pain including chronic low back pain (CLBP). OBJECTIVES: The present study was conducted to determine the prevalence of hypovitaminosis D and its contribution to chronic lower back pain. STUDY DESIGN: Controlled study. SETTING: Outpatient pain clinic of tertiary care hospital. METHODS: Data presented in this manuscript are from patients who were screened for inclusion in an open label, single arm clinical trial aimed to assess the effectiveness of vitamin D supplementation in patients with CLBP. Consecutive patients visiting the outpatient pain clinic of a tertiary care hospital with a diagnosis of CLBP with or without leg pain were recruited. A visual analogue scale (VAS) was used to measure low back pain intensity, and the Modified Oswestry disability questionnaire (MODQ) was used to measure functional ability. Plasma 25-OHD levels of all patients were measured and the prevalence of hypovitaminosis D was calculated. The multivariate logistic regression model was used to investigate the association between vitamin D deficiency and patient characteristics. RESULTS: A total of 328 patients were included in the study. Mean age of the study population was 43.8 years. Two hundred eighty-two (86%) (men 153/172 [89%], women 129/156 [83%]) of patients had below normal plasma vitamin D levels. Among these, 217 (66%) (men 126 [73%], women 91 [58%]) were found to be deficient and 65 (20%) (men 27 [16%], women 38 [24%]) were had insufficient levels. Multivariate regression analysis found that men were significantly more prone to have deficiency as compared to women (OR = 1.78 (1.10-2.88), P = 0.02). We also found a significantly positive relationship between vitamin D deficiency and increased functional disability (OR = 1.53 (1.24-1.87), P = 0.01). However, we did not find any relationship with pain severity, presence of other co-morbidities and educational level. LIMITATIONS: Not possible to access a good quality data on sun exposure and vitamin D dietary inake dieat in study population. No bone scans were performed. CONCLUSION: The result of this study provides a message about the high prevalence of hypovitaminosis D in the Indian CLBP population. Clinical guidelines for managing CLBP should include assessment of vitamin D status, together with advice on appropriate vitamin D supplementation in those found to be deficient. CLINICAL TRIAL REGISTRATION: CTRI/2014/03/004459.

Agreement between Framingham Risk Score and United Kingdom Prospective Diabetes Study Risk Engine in Identifying High Coronary Heart Disease Risk in North Indian Population

BACKGROUND: The aim of the study is to evaluate the concurrence between Framingham Risk score (FRS) and United Kingdom Prospective Diabetes Study (UKPDS) risk engine in identifying coronary heart disease (CHD) risk in newly detected diabetes mellitus patients and to explore the characteristics associated with the discrepancy between them. METHODS: A cross-sectional study involving 489 subjects newly diagnosed with type 2 diabetes mellitus was conducted. Agreement between FRS and UKPDS in classifying patients as high risk was calculated using kappa statistic. Subjects with discrepant scores between two algorithms were identified and associated variables were determined. RESULTS: The FRS identified 20.9% subjects (range, 17.5 to 24.7) as high-risk while UKPDS identified 21.75% (range, 18.3 to 25.5) as high-risk. Discrepancy was observed in 17.9% (range, 14.7 to 21.7) subjects. About 9.4% had high risk by UKPDS but not FRS, and 8.6% had high risk by FRS but not UKPDS. The best agreement was observed at high-risk threshold of 20% for both (kappa=0.463). Analysis showed that subjects having high risk on FRS but not UKPDS were elderly females having raised systolic and diastolic blood pressure. Patients with high risk on UKPDS but not FRS were males and have high glycosylated hemoglobin. CONCLUSION: The FRS and UKPDS (threshold 20%) identified different populations as being at high risk, though the agreement between them was fairly good. The concurrence of a number of factors (e.g., male sex, low high density lipoprotein cholesterol, and smoking) in both algorithms should be regarded as increasing the CHD risk. However, longitudinal follow-up is required to form firm conclusions.

Ruboxistaurin for the Treatment of Diabetic Peripheral Neuropathy: A Systematic Review of Randomized Clinical Trials

BACKGROUND: Diabetic peripheral neuropathy (DPN) is a common complication of diabetes mellitus. Protein kinase C (PKC) inhibitor's has been thought to be a potential disease modifying drug's in DPN as it slows or reverse neuropathy's progression. To assesses the efficacy and safety of ruboxistaurin on the progression of symptoms, signs, or functional disability in DPN. METHODS: A systematic review of the literature databases like PubMed, ProQuest, EBSCO, EMBASE, and Cochrane Central was performed up to August 2012. We included randomized controlled trials (RCTs) comparing PKC inhibitor ruboxistaurin (RBX) with control and lasting at least 6 months. Our primary outcome measure was change in neurological examination, measured by neurological total symptom score (NTSS) and vibration detection threshold (VDT). Secondary outcome measures were total quality of life (QoL), skin microvascular blood flow and others. RESULTS: Six RCTs were included in review. Change in neurological function assessed by NTSS was reported in six studies, out of which significant difference between the RBX and placebo group seen in four studies favouring treatment group while remaining two studies reported no significant difference. VDT was assessed in only one study in which no significant difference seen between RBX and placebo group. Two studies reported significant improvement in QoL data. Safety data was reported in only two studies in which none of side effect was related to RBX. CONCLUSION: RBX had effects on DPN in some studies, but the evidence is not enough for meta-analysis and firm conclusion.

Ruboxistaurin for the Treatment of Diabetic Peripheral Neuropathy: A Systematic Review of Randomized Clinical Trials

BACKGROUND: Diabetic peripheral neuropathy (DPN) is a common complication of diabetes mellitus. Protein kinase C (PKC) inhibitor's has been thought to be a potential disease modifying drug's in DPN as it slows or reverse neuropathy's progression. To assesses the efficacy and safety of ruboxistaurin on the progression of symptoms, signs, or functional disability in DPN. METHODS: A systematic review of the literature databases like PubMed, ProQuest, EBSCO, EMBASE, and Cochrane Central was performed up to August 2012. We included randomized controlled trials (RCTs) comparing PKC inhibitor ruboxistaurin (RBX) with control and lasting at least 6 months. Our primary outcome measure was change in neurological examination, measured by neurological total symptom score (NTSS) and vibration detection threshold (VDT). Secondary outcome measures were total quality of life (QoL), skin microvascular blood flow and others. RESULTS: Six RCTs were included in review. Change in neurological function assessed by NTSS was reported in six studies, out of which significant difference between the RBX and placebo group seen in four studies favouring treatment group while remaining two studies reported no significant difference. VDT was assessed in only one study in which no significant difference seen between RBX and placebo group. Two studies reported significant improvement in QoL data. Safety data was reported in only two studies in which none of side effect was related to RBX. CONCLUSION: RBX had effects on DPN in some studies, but the evidence is not enough for meta-analysis and firm conclusion.