Investigating the validity of the DN4 in a consecutive population of patients with chronic pain

Hans Timmerman, Monique A H Steegers, Frank J P M Huygen, Jelle J Goeman, Nick T van Dasselaar, Marcel J Schenkels, Oliver H G Wilder-Smith, André P Wolff, Kris C P Vissers, Hans Timmerman, Monique A H Steegers, Frank J P M Huygen, Jelle J Goeman, Nick T van Dasselaar, Marcel J Schenkels, Oliver H G Wilder-Smith, André P Wolff, Kris C P Vissers

Abstract

Neuropathic pain is clinically described as pain caused by a lesion or disease of the somatosensory nervous system. The aim of this study was to assess the validity of the Dutch version of the DN4, in a cross-sectional multicentre design, as a screening tool for detecting a neuropathic pain component in a large consecutive, not pre-stratified on basis of the target outcome, population of patients with chronic pain. Patients' pain was classified by two independent (pain-)physicians as the gold standard. The analysis was initially performed on the outcomes of those patients (n = 228 out of 291) in whom both physicians agreed in their pain classification. Compared to the gold standard the DN4 had a sensitivity of 75% and specificity of 76%. The DN4-symptoms (seven interview items) solely resulted in a sensitivity of 70% and a specificity of 67%. For the DN4-signs (three examination items) it was respectively 75% and 75%. In conclusion, because it seems that the DN4 helps to identify a neuropathic pain component in a consecutive population of patients with chronic pain in a moderate way, a comprehensive (physical-) examination by the physician is still obligate.

Conflict of interest statement

Competing Interests: This project is supported by an unrestricted grant from Pfizer. This unrestricted grant does not alter our adherence to PLOS ONE policies on sharing data and materials. The authors declare that they have no other competing interests.

Figures

Fig 1. Flow diagram for the outcome…
Fig 1. Flow diagram for the outcome of the physicians assessment and the NeuPSIG grading system.
Present NePC: present neuropathic pain component; Undetermined: Both physicians disagree with each other about the existence of a neuropathic pain component; Absent NePC: absent neuropathic pain component; n = total number of patients in analysis PhA: Physicians assessment; GS: Neuropathic pain special interest group grading system (missing pain classification based on the grading system: n = 8).
Fig 2. The ROC curve of the…
Fig 2. The ROC curve of the DN4, DN4 symptoms and the DN4 signs to the probability of the presence of NePC as classified based on the assessment by the physicians (A and B).
DN4: Doleur Neuropathique en 4 questions; DN4-symptoms: the items filled in by the patient; DN4 A: DN4-symptoms filled in by the patient and DN4-signs as asssessed by physicians A; DN4 B: DN4-symptoms filled in by the patient and DN4-signs as asssessed by physicians B; DN4 signs A: DN4-signs as asssessed by physicians A; DN4 signs B: DN4-signs as asssessed by physicians B.

References

    1. IASP. IASP Taxonomy Neuropathic Pain: International Association for the Study of Pain; 2015 [cited 2015 May 19, 2015]. ].
    1. Freynhagen R, Baron R, Gockel U, Tolle TR. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin. 2006;22(10):1911–20. Epub 2006/10/07. doi: .
    1. La Cesa S, Tamburin S, Tugnoli V, Sandrini G, Paolucci S, Lacerenza M, et al. How to diagnose neuropathic pain? The contribution from clinical examination, pain questionnaires and diagnostic tests. Neurological sciences: official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology. 2015;36(12):2169–75. doi: .
    1. Attal N, Perrot S, Fermanian J, Bouhassira D. The neuropathic components of chronic low back pain: a prospective multicenter study using the DN4 Questionnaire. The journal of pain: official journal of the American Pain Society. 2011;12(10):1080–7. Epub 2011/07/26. doi: .
    1. Baron R, Binder A, Attal N, Casale R, Dickenson AH, Treede RD. Neuropathic low back pain in clinical practice. European journal of pain. 2016;20(6):861–73. doi: .
    1. Freynhagen R, Baron R. The evaluation of neuropathic components in low back pain. Curr Pain Headache Rep. 2009;13(3):185–90. Epub 2009/05/22. .
    1. Haanpaa M, Attal N, Backonja M, Baron R, Bennett M, Bouhassira D, et al. NeuPSIG guidelines on neuropathic pain assessment. Pain. 2011;152(1):14–27. Epub 2010/09/21. doi: .
    1. Haanpaa ML, Backonja MM, Bennett MI, Bouhassira D, Cruccu G, Hansson PT, et al. Assessment of neuropathic pain in primary care. Am J Med. 2009;122(10 Suppl):S13–21. Epub 2009/10/07. doi: .
    1. Truini A, Cruccu G. How diagnostic tests help to disentangle the mechanisms underlying neuropathic pain symptoms in painful neuropathies. Pain. 2016;157 Suppl 1:S53–9. doi: .
    1. Dworkin RH, O′Connor AB, Kent J, Mackey SC, Raja SN, Stacey BR, et al. Interventional management of neuropathic pain: NeuPSIG recommendations. Pain. 2013;154(11):2249–61. Epub 2013/06/12. doi: .
    1. Bennett MI, Attal N, Backonja MM, Baron R, Bouhassira D, Freynhagen R, et al. Using screening tools to identify neuropathic pain. Pain. 2007;127(3):199–203. Epub 2006/12/22. doi: .
    1. Bouhassira D, Attal N. Diagnosis and assessment of neuropathic pain: the saga of clinical tools. Pain. 2011;152(3 Suppl):S74–83. doi: .
    1. Andermann A, Blancquaert I, Beauchamp S, Dery V. Revisiting Wilson and Jungner in the genomic age: a review of screening criteria over the past 40 years. Bull World Health Organ. 2008;86(4):317–9. doi:
    1. Wilson JM, Jungner YG. [Principles and practice of mass screening for disease]. Bol Oficina Sanit Panam. 1968;65(4):281–393. .
    1. Dieleman JP, Kerklaan J, Huygen FJ, Bouma PA, Sturkenboom MC. Incidence rates and treatment of neuropathic pain conditions in the general population. Pain. 2008;137(3):681–8. Epub 2008/04/29. doi: .
    1. Mathieson S, Maher CG, Terwee CB, Folly de Campos T, Lin CW. Neuropathic pain screening questionnaires have limited measurement properties. A systematic review. Journal of clinical epidemiology. 2015;68(8):957–66. doi: .
    1. Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain. 2005;114(1–2):29–36. Epub 2005/03/01. .
    1. CADTH. Diagnostic methods for neuropathic pain: A review of diagnostic accuracy. Canadian Agency for Drugs and Technologies in Health [Internet]. 2015 10-28-2015 [cited 2015. .
    1. Proqolid. neuropathic pain 4 questions: MAPI Research trust; 2015 [cited 2015].].
    1. Van Seventer R, Vos C, Meerding W, Mear I, Le Gal M, Bouhassira D, et al. Linguistic validation of the DN4 for use in international studies. European journal of pain. 2010;14(1):58–63. Epub 2009/03/14. doi: .
    1. Perez C, Galvez R, Huelbes S, Insausti J, Bouhassira D, Diaz S, et al. Validity and reliability of the Spanish version of the DN4 (Douleur Neuropathique 4 questions) questionnaire for differential diagnosis of pain syndromes associated to a neuropathic or somatic component. Health Qual Life Outcomes. 2007;5:66 doi:
    1. Harifi G, Ouilki I, El Bouchti I, Ouazar MA, Belkhou A, Younsi R, et al. Validity and reliability of the Arabic adapted version of the DN4 questionnaire (Douleur Neuropathique 4 Questions) for differential diagnosis of pain syndromes with a neuropathic or somatic component. Pain practice: the official journal of World Institute of Pain. 2011;11(2):139–47. doi: .
    1. Unal-Cevik I, Sarioglu-Ay S, Evcik D. A comparison of the DN4 and LANSS questionnaires in the assessment of neuropathic pain: validity and reliability of the Turkish version of DN4. The journal of pain: official journal of the American Pain Society. 2010;11(11):1129–35. doi: .
    1. Santos JG, Brito JO, de Andrade DC, Kaziyama VM, Ferreira KA, Souza I, et al. Translation to Portuguese and validation of the Douleur Neuropathique 4 questionnaire. The journal of pain: official journal of the American Pain Society. 2010;11(5):484–90. doi: .
    1. van Seventer R, Vos C, Giezeman M, Meerding WJ, Arnould B, Regnault A, et al. Validation of the Dutch version of the DN4 diagnostic questionnaire for neuropathic pain. Pain practice: the official journal of World Institute of Pain. 2013;13(5):390–8. doi: .
    1. Madani SP, Fateh HR, Forogh B, Fereshtehnejad SM, Ahadi T, Ghaboussi P, et al. Validity and reliability of the persian (Farsi) version of the DN4 (Douleur Neuropathique 4 Questions) questionnaire for differential diagnosis of neuropathic from non-neuropathic pains. Pain practice: the official journal of World Institute of Pain. 2014;14(5):427–36. doi: .
    1. Sykioti P, Zis P, Vadalouca A, Siafaka I, Argyra E, Bouhassira D, et al. Validation of the Greek Version of the DN4 Diagnostic Questionnaire for Neuropathic Pain. Pain practice: the official journal of World Institute of Pain. 2014. doi: .
    1. Hamdan A, Luna JD, Del Pozo E, Galvez R. Diagnostic accuracy of two questionnaires for the detection of neuropathic pain in the Spanish population. European journal of pain. 2014;18(1):101–9. doi: .
    1. Chaudakshetrin P, Prateepavanich P, Chira-Adisai W, Tassanawipas W, Leechavengvongs S, Kitisomprayoonkul W. Cross-cultural adaptation to the Thai language of the neuropathic pain diagnostic questionnaire (DN4). J Med Assoc Thai. 2007;90(9):1860–5. .
    1. Kim HJ, Park JH, Bouhassira D, Shin JH, Chang BS, Lee CK, et al. Validation of the Korean Version of the DN4 Diagnostic Questionnaire for Neuropathic Pain in Patients with Lumbar or Lumbar-Radicular Pain. Yonsei Med J. 2016;57(2):449–54. doi:
    1. Chatila N, Pereira B, Maarrawi J, Dallel R. Validation of a New Arabic Version of the Neuropathic Pain Diagnostic Questionnaire (DN4). Pain practice: the official journal of World Institute of Pain. 2016. doi: .
    1. Treede RD, Jensen TS, Campbell JN, Cruccu G, Dostrovsky JO, Griffin JW, et al. Neuropathic pain: redefinition and a grading system for clinical and research purposes. Neurology. 2008;70(18):1630–5. Epub 2007/11/16. doi: .
    1. Finnerup NB, Haroutounian S, Kamerman P, Baron R, Bennett DL, Bouhassira D, et al. Neuropathic pain: an updated grading system for research and clinical practice. Pain. 2016. .
    1. Geber C, Baumgartner U, Schwab R, Muller H, Stoeter P, Dieterich M, et al. Revised definition of neuropathic pain and its grading system: an open case series illustrating its use in clinical practice. Am J Med. 2009;122(10 Suppl):S3–12. doi: .
    1. Mulvey MR, Rolke R, Klepstad P, Caraceni A, Fallon M, Colvin L, et al. Confirming neuropathic pain in cancer patients: applying the NeuPSIG grading system in clinical practice and clinical research. Pain. 2014;155(5):859–63. doi: .
    1. Abdallah FW, Morgan PJ, Cil T, Escallon JM, Semple JL, Chan VW. Comparing the DN4 tool with the IASP grading system for chronic neuropathic pain screening after breast tumor resection with and without paravertebral blocks: a prospective 6-month validation study. Pain. 2015;156(4):740–9. .
    1. Guastella V, Mick G, Soriano C, Vallet L, Escande G, Dubray C, et al. A prospective study of neuropathic pain induced by thoracotomy: incidence, clinical description, and diagnosis. Pain. 2011;152(1):74–81. doi: .
    1. Timmerman H, Heemstra I, Schalkwijk A, Verhagen C, Vissers K, Engels Y. Assessment of Neuropathic Pain in Patients with Cancer: The Interobserver Reliability. An Observational Study in Daily Practice. Pain physician. 2013;(16):11.
    1. Timmerman H, Wilder-Smith O, van Weel C, Wolff A, Vissers K. Detecting the neuropathic pain component in the clinical setting: a study protocol for validation of screening instruments for the presence of a neuropathic pain component. BMC Neurol. 2014;14(1):94 Epub 2014/06/03. doi:
    1. Lavand′homme P, Thienpont E. Pain after total knee arthroplasty: a narrative review focusing on the stratification of patients at risk for persistent pain. Bone Joint J. 2015;97-B(10 Suppl A):45–8. doi: .
    1. Cruccu G, Anand P, Attal N, Garcia-Larrea L, Haanpaa M, Jorum E, et al. EFNS guidelines on neuropathic pain assessment. European journal of neurology. 2004;11(3):153–62. .
    1. Cruccu G, Sommer C, Anand P, Attal N, Baron R, Garcia-Larrea L, et al. EFNS guidelines on neuropathic pain assessment: revised 2009. European journal of neurology. 2010;17(8):1010–8. Epub 2010/03/20. doi: .
    1. Tampin B, Briffa NK, Goucke R, Slater H. Identification of neuropathic pain in patients with neck/upper limb pain: application of a grading system and screening tools. Pain. 2013;154(12):2813–22. Epub 2013/08/27. doi: .
    1. Vaegter HB, Andersen PG, Madsen MF, Handberg G, Enggaard TP. Prevalence of neuropathic pain according to the IASP grading system in patients with chronic non-malignant pain. Pain Med. 2014;15(1):120–7. doi: .
    1. Collins SL, Edwards J, Moore RA, Smith LA, McQuay HJ. Seeking a simple measure of analgesia for mega-trials: is a single global assessment good enough? Pain. 2001;91(1–2):189–94. Epub 2001/03/10. .
    1. Farrar JT, Young JP Jr., LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94(2):149–58. Epub 2001/11/03. .
    1. Fischer D, Stewart AL, Bloch DA, Lorig K, Laurent D, Holman H. Capturing the patient′s view of change as a clinical outcome measure. Jama. 1999;282(12):1157–62. Epub 1999/09/29. .
    1. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–74. Epub 1977/03/01. .
    1. El Khouli RH, Macura KJ, Barker PB, Habba MR, Jacobs MA, Bluemke DA. Relationship of temporal resolution to diagnostic performance for dynamic contrast enhanced MRI of the breast. J Magn Reson Imaging. 2009;30(5):999–1004. doi:
    1. Obuchowski NA. Receiver operating characteristic curves and their use in radiology. Radiology. 2003;229(1):3–8. doi: .
    1. Ludemann L, Grieger W, Wurm R, Wust P, Zimmer C. Glioma assessment using quantitative blood volume maps generated by T1-weighted dynamic contrast-enhanced magnetic resonance imaging: a receiver operating characteristic study. Acta Radiol. 2006;47(3):303–10. .
    1. Metz CE. Basic principles of ROC analysis. Semin Nucl Med. 1978;8(4):283–98. .
    1. Greenhalgh T. How to read a paper: Papers that report diagnostic or screening tests (vol 315, pg 540, 1997). British Medical Journal. 1997;315(7113):942-.
    1. Cicchetti DV. Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment. 1994;6(4):6.
    1. Cicchetti DV, Sparrow SA. Developing criteria for establishing interrater reliability of specific items: applications to assessment of adaptive behavior. American journal of mental deficiency. 1981;86(2):127–37. .
    1. Versi E. "Gold standard" is an appropriate term. British Medical Journal. 1992;305:187.
    1. Versi E. Discriminant analysis of urethral pressure profilometry data for the diagnosis of genuine stress incontinence. British journal of obstetrics and gynaecology. 1990;97(3):251–9. .
    1. Kimberlin CL, Winterstein AG. Validity and reliability of measurement instruments used in research. American journal of health-system pharmacy: AJHP: official journal of the American Society of Health-System Pharmacists. 2008;65(23):2276–84. doi: .
    1. Altman DG, Bland JM. Diagnostic tests. 1: Sensitivity and specificity. Bmj. 1994;308(6943):1552
    1. Altman DG, Bland JM. Diagnostic tests 2: Predictive values. Bmj. 1994;309(6947):102
    1. Grimes DA, Schulz KF. Uses and abuses of screening tests. Lancet. 2002;359(9309):881–4. doi: .
    1. Themistocleous AC, Ramirez JD, Shillo PR, Lees JG, Selvarajah D, Orengo C, et al. The Pain in Neuropathy Study (PiNS): a cross-sectional observational study determining the somatosensory phenotype of painful and painless diabetic neuropathy. Pain. 2016;157(5):1132–45.
    1. Spallone V, Morganti R, D′Amato C, Greco C, Cacciotti L, Marfia GA. Validation of DN4 as a screening tool for neuropathic pain in painful diabetic polyneuropathy. Diabet Med. 2012;29(5):578–85. doi: .
    1. Hallstrom H, Norrbrink C. Screening tools for neuropathic pain: can they be of use in individuals with spinal cord injury? Pain. 2011;152(4):772–9. Epub 2011/01/29. doi: .
    1. Lasry-Levy E, Hietaharju A, Pai V, Ganapati R, Rice AS, Haanpaa M, et al. Neuropathic pain and psychological morbidity in patients with treated leprosy: a cross-sectional prevalence study in Mumbai. PLoS Negl Trop Dis. 2011;5(3):e981 doi:
    1. Haroun OM, Hietaharju A, Bizuneh E, Tesfaye F, Brandsma JW, Haanpaa M, et al. Investigation of neuropathic pain in treated leprosy patients in Ethiopia: a cross-sectional study. Pain. 2012;153(8):1620–4. doi: .
    1. Markman JD, Kress BT, Frazer M, Hanson R, Kogan V, Huang JH. Screening for neuropathic characteristics in failed back surgery syndromes: challenges for guiding treatment. Pain Med. 2015;16(3):520–30. doi: .
    1. Geber C, Breimhorst M, Burbach B, Egenolf C, Baier B, Fechir M, et al. Pain in chemotherapy-induced neuropathy—more than neuropathic? Pain. 2013;154(12):2877–87. .
    1. Sadler A, Wilson J, Colvin L. Acute and chronic neuropathic pain in the hospital setting: use of screening tools. The Clinical journal of pain. 2013;29(6):507–11. .
    1. VanDenKerkhof EG, Mann EG, Torrance N, Smith BH, Johnson A, Gilron I. An Epidemiological Study of Neuropathic Pain Symptoms in Canadian Adults. Pain research & management. 2016;2016:9815750 doi:
    1. Deeks JJ. Systematic reviews in health care: Systematic reviews of evaluations of diagnostic and screening tests. Bmj. 2001;323(7305):157–62.

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