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      Neuropathic pain in the community: More under-treated than refractory?

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          Summary

          There is a significant proportion of chronic pain that is persistent and neuropathic, appears undertreated or untreated, and is associated with poor health and quality of life.

          Abstract

          Best current estimates of neuropathic pain prevalence come from studies using screening tools detecting pain with probable neuropathic features; the proportion experiencing significant, long-term neuropathic pain, and the proportion not responding to standard treatment are unknown. These “refractory” cases are the most clinically important to detect, being the most severe, requiring specialist treatment. The aim of this study was to estimate the proportion of neuropathic pain in the population that is “refractory,” and to quantify associated clinical and demographic features. We posted self-administered questionnaires to 10,000 adult patients randomly selected from 10 general practitioner practices in 5 UK locations. The questionnaire contained chronic pain identification and severity questions, cause of pain, SF-12, EQ-5D, S-LANSS (Self-administered Leeds Assessment of Neuropathic Signs and Symptoms), PSEQ (Pain Self-Efficacy Questionnaire), use of neuropathic pain medications, and health care utilisation. These data were combined to determine the presence and characteristics of “refractory” neuropathic pain according to the defining features identified by a Delphi survey of international experts. Graded categories of chronic pain with and without neuropathic characteristics were generated, incorporating the refractory criteria. Completed questionnaires were returned by 4451 individuals (response rate 47%); 399 had “chronic pain with neuropathic characteristics” (S-LANSS positive, 8.9% of the study sample); 215 (53.9%) also reported a positive relevant history (“Possible neuropathic pain”); and 98 (4.5% of all Chronic Pain) also reported an “adequate” trial of at least one neuropathic pain drug (“Treated possible neuropathic pain”). The most refractory cases were associated with dramatically poorer physical and mental health, lower pain self-efficacy, higher pain intensity and pain-related disability, and greater health care service use.

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          Most cited references 47

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          EuroQol--a new facility for the measurement of health-related quality of life.

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          In the course of developing a standardised, non-disease-specific instrument for describing and valuing health states (based on the items in Table 1), the EuroQol Group (whose members are listed in the Appendix) conducted postal surveys in England, The Netherlands and Sweden which indicate a striking similarity in the relative valuations attached to 14 different health states. The data were collected using a visual analogue scale similar to a thermometer. The EuroQol instrument is intended to complement other quality-of-life measures and to facilitate the collection of a common data set for reference purposes. Others interested in participating in the extension of this work are invited to contact the EuroQol Group.
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            A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity.

            Regression methods were used to select and score 12 items from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) to reproduce the Physical Component Summary and Mental Component Summary scales in the general US population (n=2,333). The resulting 12-item short-form (SF-12) achieved multiple R squares of 0.911 and 0.918 in predictions of the SF-36 Physical Component Summary and SF-36 Mental Component Summary scores, respectively. Scoring algorithms from the general population used to score 12-item versions of the two components (Physical Components Summary and Mental Component Summary) achieved R squares of 0.905 with the SF-36 Physical Component Summary and 0.938 with SF-36 Mental Component Summary when cross-validated in the Medical Outcomes Study. Test-retest (2-week)correlations of 0.89 and 0.76 were observed for the 12-item Physical Component Summary and the 12-item Mental Component Summary, respectively, in the general US population (n=232). Twenty cross-sectional and longitudinal tests of empirical validity previously published for the 36-item short-form scales and summary measures were replicated for the 12-item Physical Component Summary and the 12-item Mental Component Summary, including comparisons between patient groups known to differ or to change in terms of the presence and seriousness of physical and mental conditions, acute symptoms, age and aging, self-reported 1-year changes in health, and recovery for depression. In 14 validity tests involving physical criteria, relative validity estimates for the 12-item Physical Component Summary ranged from 0.43 to 0.93 (median=0.67) in comparison with the best 36-item short-form scale. Relative validity estimates for the 12-item Mental Component Summary in 6 tests involving mental criteria ranged from 0.60 to 107 (median=0.97) in relation to the best 36-item short-form scale. Average scores for the 2 summary measures, and those for most scales in the 8-scale profile based on the 12-item short-form, closely mirrored those for the 36-item short-form, although standard errors were nearly always larger for the 12-item short-form.
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              Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment.

              This large scale computer-assisted telephone survey was undertaken to explore the prevalence, severity, treatment and impact of chronic pain in 15 European countries and Israel. Screening interviews identified respondents aged 18 years with chronic pain for in-depth interviews. 19% of 46,394 respondents willing to participate (refusal rate 46%) had suffered pain for 6 months, had experienced pain in the last month and several times during the last week. Their pain intensity was 5 on a 10-point Numeric Rating Scale (NRS) (1 = no pain, 10 = worst pain imaginable) during last episode of pain. In-depth interviews with 4839 respondents with chronic pain (about 300 per country) showed: 66% had moderate pain (NRS = 5-7), 34% had severe pain (NRS = 8-10), 46% had constant pain, 54% had intermittent pain. 59% had suffered with pain for two to 15 years, 21% had been diagnosed with depression because of their pain, 61% were less able or unable to work outside the home, 19% had lost their job and 13% had changed jobs because of their pain. 60% visited their doctor about their pain 2-9 times in the last six months. Only 2% were currently treated by a pain management specialist. One-third of the chronic pain sufferers were currently not being treated. Two-thirds used non-medication treatments, e.g,. massage (30%), physical therapy (21%), acupuncture (13%). Almost half were taking non-prescription analgesics; 'over the counter' (OTC) NSAIDs (55%), paracetamol (43%), weak opioids (13%). Two-thirds were taking prescription medicines: NSAIDs (44%), weak opioids (23%), paracetamol (18%), COX-2 inhibitors (1-36%), and strong opioids (5%). Forty percent had inadequate management of their pain. Interesting differences between countries were observed, possibly reflecting differences in cultural background and local traditions in managing chronic pain. Chronic pain of moderate to severe intensity occurs in 19% of adult Europeans, seriously affecting the quality of their social and working lives. Very few were managed by pain specialists and nearly half received inadequate pain management. Although differences were observed between the 16 countries, we have documented that chronic pain is a major health care problem in Europe that needs to be taken more seriously.
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                Author and article information

                Affiliations
                [a ]Medical Research Institute, University of Dundee, Dundee, UK
                [b ]Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
                [c ]Academic Unit of Palliative Care, University of Leeds, Leeds, UK
                [d ]School of Medicine, University of Glasgow, Glasgow, UK
                [e ]Institute of Primary Care & Health Sciences, University of Keele, Keele, UK
                Author notes
                [* ]Corresponding author. Address: University of Dundee, Medical Research Institute, Ninewells Hospital & Medical School, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK. Tel.: +44 0 1382 383476. n.torrance@ 123456dundee.ac.uk
                Contributors
                Journal
                Pain
                Pain
                Pain
                Elsevier/North-Holland
                0304-3959
                1872-6623
                1 May 2013
                May 2013
                : 154
                : 5
                : 690-699
                23485369
                3630326
                PAIN8650
                10.1016/j.pain.2012.12.022
                © 2013 Elsevier B.V.

                This document may be redistributed and reused, subject to certain conditions.

                Categories
                Article

                Anesthesiology & Pain management

                neuropathic pain, chronic pain, epidemiology, s-lanss, refractory

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