Entre rejas (Spanish Edition)

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In particular, in addition to the general diagnostic properties of our translated questionnaire i.

The DN4 was also administered to a group of patients with a combination of neuropathic and non-neuropathic pain to support its validity in mixed pain syndromes. The DN4 questionnaire [ 15 ] consists of a total of 10 items grouped in 4 sections [Additional file 1 ]. The first seven items are related to the quality of pain burning, painful cold, electric shocks and its association to abnormal sensations tingling, pins and needles, numbness, itching. The other 3 items are related to neurological examination in the painful area touch hypoesthesia, pinprick hypoesthesia, tactile allodynia.

A score of 1 is given to each positive item and a score of 0 to each negative item. All questions are related to pain which is the claim for current medical consultation. The adaptation into Spanish of the DN4 questionnaire and the subsequent assessment of its psychometric properties i.

In the preparation phase, an expert panel was selected, the original questionnaire was translated, the sample was defined, and the study documentation was prepared. The adaptation procedure was monitored by a five-expert panel including three specialists in pain management, an expert in methodology, and an expert in clinical research.

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These experts reviewed the translation and monitored the adaptation process. As the original version of the questionnaire was well defined and structured, the expert panel did not consider it necessary to redefine its sections or reformulate the original questions. No cultural bias that could be equivocal or non-translatable was detected in the original instrument. Questionnaire translation was commissioned to two independent professional translators philologists, Spanish natives to have two parallel translations.

The final version was back-translated into French by two other professional translators different from the first two translators, and French natives and submitted to the original author Dr. D Bouhassira , who proposed a change in the translation of one of the descriptors in the pain scale to certify agreement with the original instrument. Patients of both sexes with chronic pain for more than 3 months aged 18 years or over, with an adequate cultural level to understand health questionnaires administered in Spanish were included in this study.

Chronic pain could be of a neuropathic, non-neuropathic, or mixed i. Pain was classified based on the medical history, physical examination, and any procedures laboratory tests, electrophysiology, imaging, etc. All patients gave their written informed consent before entering the study. Demographic characteristics of study patients, overall and by the main subgroups with NP and without NNP associated neuropathic component. Distribution of the most common etiological causes of neuropathic pain peripheral and central , mixed pain and non-neuropathic pain in the study patients.

The SF-MPQ includes 15 items related to the presence and severity assessed with a 4-point Likert scale of pain descriptors associated to the affective 4 items or sensory 11 items dimensions of chronic pain. All investigators were pain experts. At each participating center, the main investigator collected the sociodemographic and clinical data required for patient characterization and was required to classify patients into two broad diagnostic categories corresponding to NP and NNP, and to further subcategorize NP into peripheral, central or mixed pain.

The diagnosis of the principal investigator was considered as the reference gold standard diagnosis. Patients were then separately seen within 2 days by two other investigators raters A and B blinded to the diagnosis proposed by the principal investigator, who administered the DN4 and SF-McGill questionnaires. This study was conducted according with usual standard of care in each participant centre, and it did not involve any drug or therapeutic management. Inter-rater reliability was assessed by the agreement of the results obtained by raters A and B for each item and the total score of the DN4 questionnaire.

Agreement was determined by calculating the Cohen's kappa coefficient. Inter-rater agreement was also determined by calculating the intra-class correlation coefficient of the total scores assigned by each pair of raters to the same subject, and the answers to each individual item, using a two-factor model and mixed effects. Stability of the questionnaire was analyzed by measuring the intra-class correlation coefficient between the scores of clinicians completing test and retest and using Cohen's kappa coefficient of agreement for the total retest sample and in subgroups by type of pain.

A ROC receiver operating characteristic curve analysis was performed to determine the cut-off value of the questionnaire score providing the best values of sensitivity and specificity for NP diagnosis and determination of Youden's index for the total patient sample included in the study.

This was repeated in two sub-samples excluding either patients with mixed pain only or patients with mixed and subjects with central NP just to test the instrument in patients with peripheral NP only. For each cut-off value of the scale score, in addition to sensitivity and specificity and Youden's index, the positive PPV and negative predictive value NPV , the kappa coefficient of agreement with the diagnosis according to the standard criterion or reference diagnosis, and the area under the curve AUC calculated by the trapezoid method and its significance level were estimated.

Validity indicators sensitivity, specificity, PPV, and NPV were recalculated individually for the presence of each descriptor symptom of the DN4 questionnaire. The Youden's index was calculated by the equation: Descriptive statistics were prepared for the variables tested in this study to assess central positition, dispersion, and distribution of variables tested by the Kolmogorov- Smirnov test. A Student's t test for independent groups or a Mann-Whitney's U test was used in the case of a non-normal distribution to compare continuous or ordinal variables respectively between patients with NP and NNP.

Data were analyzed using SPSS version The study was conducted from June to November Internal consistency, inter-rater agreement, and test-retest reliability of the Spanish version of the DN4 questionnaire. Inter-rater reliability, which is essential for an instrument that contains a semi-structured interview subject to interviewer interpretation, was good to very good.

The total scores in each diagnostic group did not show statistically significant differences, and the intra-class correlation coefficient values ranged from 0. Calculation of the kappa coefficients supported the inter-rater agreement regarding diagnostic classification.

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In addition, retest results confirmed that the DN4 questionnaire has good test-retest stability, with intra-class correlation coefficients ranging from 0. In all cases, ROC curve analysis identified a score of 4 as the best cut-off value discriminating between NP and NNP values of the area under the curve ranging from 0. Cut-off point in the DN4 questionnaire optimizing the sensitivity and specificity values for discriminating between neuropathic pain and non-neuropathic pain in the overall sample. Cut-off point in the DN4 questionnaire optimizing the sensitivity and specificity values for discriminating between pure neuropathic pain excluding patients with mixed pain and non-neuropathic pain.

Cut-off point in the DN4 questionnaire optimizing the sensitivity and specificity values for discriminating between peripheral neuropathic pain excluding patients with mixed pain and central neuropathic pain and non-neuropathic pain. Questionnaire performance was not significantly influenced by the educational level, but was significantly decreased in patients with mild pain. Properties of validity for diagnosis of pain with neuropathic involvement in different subgroups by pain severity and educational level in the overall sample. Two patients did not report their educational level.

This study represents the first validation of the DN4 questionnaire, originally validated into French, into another language. Overall, the high discriminant value of the Spanish version of the DN4 questionnaire for identification of neuropathic pain was confirmed. In addition, our study provided new information about the test-retest reliability of the questionnaire, the influence of educational level and pain intensity on its performance, and its validity in mixed pain syndromes.

Identification of neuropathic components is crucial for characterization of chronic pain patients and to adapt the therapeutic approach, given the differential response of neuropathic pain to analgesic treatment [ 7 , 28 , 29 ]. Therefore, a better identification of neuropathic pain should improve the therapeutic outcome. Several diagnostic and screening tools have been developed and validated over the past few years for this purpose [ 19 ].

The DN4, initially developed and validated in French-speaking patients, has very high diagnostic properties [ 15 ] and is one of the easiest tools to use. In particular, its scoring is very simple because, unlike in other tools, the items are not "weighted". In the original study, only patients with "pure" neuropathic pain i. Thus, in addition to the linguistic validation of the DN4 questionnaire into Spanish, it appeared of interest to provide additional psychometric validation of this questionnaire.

The reliability and validity of the Spanish version of the DN4 questionnaire were confirmed; in particular, our analyses showed that, similarly to the French version, the best cut-off value corresponds to a total score of 4 out of The overall performance of the Spanish DN4 questionnaire was very good, although specificity and sensitivity appeared to be slightly lower as compared to the original version. These differences might reflect linguistic specificities and cultural differences, but they may also result from methodological disparities e.

In particular, our analysis of the properties of the questionnaire according to pain intensity revealed significantly lower sensitivity and specificity in patients with mild pain intensity.

Van Thuan. Libre entre rejas | New Spanish Books UK

The influence of pain intensity on the psychometric properties of neuropathic pain screening tools had not been previously tested with the DN4 or with other questionnaires. The data reported here suggest that these tools might be much less discriminant and should therefore be used with caution in patients with reduced pain intensity.

However, this would have to be confirmed in further studies with the DN4 or other diagnostic questionnaires, because the subgroup of patients with mild pain intensity was relatively small in this study. By contrast, our results suggest that the discriminant value of the DN4 questionnaire did not depend on the educational level, confirming that these simple symptom-based questionnaires are easily understood and that their administration should not be restricted to highly educated patients. A supplemental validation investigated in this study concerned the stability over time i.

The results of the DN4 were similar in patients with "pure" neuropathic pain or mixed pain syndromes, i. Thus, the present data suggest that the neuropathic component of the "mixed pain" syndrome has clinical characteristics similar to those of "pure" neuropathic pain. Interestingly, this is consistent with the results recently reported by Freynhagen et al [ 17 ], showing that radiculopathies associated with mixed pain syndromes have clinical characteristics similar to those of definite neuropathic pain syndromes.

In addition, the statistical estimators of validity of the test remained mostly unchanged after removing both the subgroups of patients with mixed pain and with central pain, leaving pure peripheral neuropathic pain only. This suggests that the error level of the questionnaire will remain largely unchanged. More generally, our data tend to support the interest of NP screening tools in the clinical setting. These tools should be of particular interest for both Primary Care Physicians PCPs and other non pain specialists to identify NP, diagnose its cause, and adapt the analgesic treatment.

Thus, screening tools like DN4 should help PCPs to take a more pro-active role in appropriate treatment selection, thus avoiding early therapeutic failure and patient suffering. The results of this study support the transcultural validity of the DN4 questionnaire. More generally, our data tend to confirm the interest of symptom-based diagnostic tools for identification of the neuropathic pain component. These simple clinical tools may be used not only in daily practice, but also in the clinical research setting e.

Future studies directly comparing the performance of the different available tools are warranted. Javier Rejas is employed at Pfizer Spain.