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Diagnostic utility of patient history, clinical examination and screening tool data to identify neuropathic pain in low back-related leg pain: protocol for a systematic review.

ABSTRACT: INTRODUCTION:Neuropathic low back-related leg pain (LBLP) can be a challenge to healthcare providers to diagnose and treat. Accurate diagnosis of neuropathic pain is fundamental to ensure appropriate intervention is given. However, to date there is no gold standard to diagnose neuropathic LBLP. Patient examination guidelines and screening tools have been developed and validated for the purpose of diagnosing neuropathic pain in LBLP; however, there has been no systematic review conducted to compare the diagnostic validity of these methods. Therefore, this systematic review will investigate the diagnostic utility of patient history, clinical examination and screening tool data to identify neuropathic pain in LBLP. METHODS AND ANALYSIS:This protocol is informed and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Protocols. CINAHL, EMBASE, MEDLINE, Web of Science, Cochrane Library, AMED, Pedro, PubMed, key journals and grey literature will be searched rigorously to find diagnostic accuracy studies investigating patient examination data to identify neuropathic pain in LBLP patients. Two independent reviewers will conduct the search, extract the data and assess risk of bias for included studies using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. The overall quality of included studies will be evaluated using Grading of Recommendations, Assessment, Development and Evaluation guidelines. A meta-analysis will be conducted if deemed appropriate. Otherwise, a narrative synthesis will be conducted. ETHICS AND DISSEMINATION:No research ethics is required for this systematic review since patient data will not be collected. This review will help to inform healthcare professionals and researchers on the most effective means in which to diagnose neuropathic pain in LBLP. Results of this review will be submitted for publication in a peer-review journal and conference presentations. PROSPERO REGISTRATION NUMBER:CRD42019140861.

SUBMITTER: Mistry J

PROVIDER: S-EPMC6887074 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

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Diagnostic utility of patient history, clinical examination and screening tool data to identify neuropathic pain in low back-related leg pain: protocol for a systematic review.

Mistry Jai J Heneghan Nicola R NR Noblet Timothy T Falla Deborah D Rushton Alison A

BMJ open 20191124 11

<h4>Introduction</h4>Neuropathic low back-related leg pain (LBLP) can be a challenge to healthcare providers to diagnose and treat. Accurate diagnosis of neuropathic pain is fundamental to ensure appropriate intervention is given. However, to date there is no gold standard to diagnose neuropathic LBLP. Patient examination guidelines and screening tools have been developed and validated for the purpose of diagnosing neuropathic pain in LBLP; however, there has been no systematic review conducted ...[more]

PMID: 31767596

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Project description:Background and objectiveLow back pain (LBP) is one of the most common chronic pain conditions. This paper reviews the available literature on the role of neuropathic mechanisms in chronic LBP and discusses implications for its clinical management, with a particular focus on pharmacological treatments.Databases and data treatmentLiterature searches were performed in PubMed, key pain congresses and ProQuest Dialog to identify published evidence on neuropathic back pain and its management. All titles were assessed for relevant literature.ResultsChronic LBP comprises both nociceptive and neuropathic components, however, the neuropathic component appears under-recognized and undertreated. Neuropathic pain (NP) is challenging to manage. Many patients with chronic LBP have pain that is refractory to existing treatments. Typically, less than half of patients experience clinically meaningful analgesia with oral pharmacotherapies; these are also associated with risks of adverse effects. Paracetamol and NSAIDs, although widely used for LBP, are unlikely to ameliorate the neuropathic component and data on the use of NP medications such as antidepressants and gabapentin/pregabalin are limited. While there is an unmet need for improved treatment options, recent data have shown tapentadol to have efficacy in the neuropathic component of LBP, and studies suggest that the capsaicin 8% patch and lidocaine 5% medicated plaster, topical analgesics available for the treatment of peripheral NP, may be a valuable additional approach for the management of neuropathic LBP.ConclusionsChronic LBP often has an under-recognized neuropathic component, which can be challenging to manage, and requires improved understanding and better diagnosis and treatment. WHAT DOES THIS REVIEW ADD?: Increased recognition and improved understanding of the neuropathic component of low back pain raises the potential for the development of mechanism-based therapies. Open and retrospective studies suggest that agents like tapentadol and topical analgesics - such as the capsaicin 8% patch and the lidocaine 5% medicated plaster - may be effective options for the treatment of neuropathic low back pain in defined patient groups.

Project description:BACKGROUND CONTEXT:Evidence is lacking on the prognosis and prognostic factors of back-related leg pain and sciatica in patients seeing their primary care physicians. This evidence could guide timely appropriate treatment and referral decisions. PURPOSE:The present study aims to describe the prognosis and prognostic factors in primary care patients with low back-related leg pain and sciatica. STUDY DESIGN:This is a prospective cohort study. PATIENT SAMPLE:The present study included adults visiting their family doctor with back-related leg pain in the United Kingdom. OUTCOME MEASURES:Information about pain, function, psychological, and clinical variables, was collected. Good outcome was defined as 30% or more reduction in disability (Roland-Morris Disability Questionnaire). METHODS:Participants completed the questionnaires, underwent clinical assessments, received a magnetic resonance imaging scan, and were followed-up 12 months later. Mixed-effects logistic regression evaluated the prognostic value of six a priori defined variable sets (leg pain duration, pain intensity, neuropathic pain, psychological factors, clinical examination, and imaging variables). A combined model, including variables from all models, examined independent effects. The National Institute for Health Research funded the study. There are no conflicts of interest. RESULTS:A total of 609 patients were included. At 12 months, 55% of patients improved in both the total sample and the sciatica group. For the whole cohort, longer leg pain duration (odds ratio [OR] 0.41; confidence interval [CI] 0.19-0.90), higher identity score (OR 0.70; CI 0.53-0.93), and patient's belief that the problem will last a long time (OR 0.27; CI 0.13-0.57) were the strongest independent prognostic factors negatively associated with improvement. These last two factors were similarly negatively associated with improvement in the sciatica subgroup. CONCLUSIONS:The present study provides new evidence on the prognosis and prognostic factors of back-related leg pain and sciatica in primary care. Just over half of patients improved at 12 months. Patient's belief of recovery timescale and number of other symptoms attributed to the pain are independent prognostic factors. These factors can be used to inform and direct decisions about timing and intensity of available therapeutic options.

Project description:BackgroundAdequate 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 findingsUsing 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.ConclusionsWe 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.

Dataset Information

Diagnostic utility of patient history, clinical examination and screening tool data to identify neuropathic pain in low back-related leg pain: protocol for a systematic review.

Publications

Diagnostic utility of patient history, clinical examination and screening tool data to identify neuropathic pain in low back-related leg pain: protocol for a systematic review.

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