Brazilian Portuguese Validation of the Leeds ?· Brazilian Portuguese Validation of the Leeds Assessment…
Brazilian Portuguese Validation of the LeedsAssessment of Neuropathic Symptoms andSigns for Patients with Chronic Painpme_1221 1544..1550Pedro Schestatsky, MD, PhD,* Vitor Flix-Torres,MD,* Mrcia Lorena Fagundes Chaves, MD, PhD,*Betnia Cmara-Ehlers, MD,* Tamara Mucenic,MD, Wolnei Caumo, MD, PhD,Osvaldo Nascimento, MD, PhD, andMichael I. Bennett, MD*Neurology Service,Rheumatology Service, andPain and Palliative Care Service, Hospital de Clnicasde Porto Alegre, Porto Alegre, Brazil;Department of Neurology, Fluminense FederalUniversity, Niteri-RJ, Brazil;School of Health and Medicine, Bowland Tower East,Lancaster University, UKReprint requests to: Dr. Pedro Schestatsky, MD, PhD,Hospital de Clnicas de Porto Alegre, NeurologyDepartment, EMG Unit, Rua Ramiro Barcelos,2350CEP 90035-003, Brazil. Tel: 513-359-8564; Fax:513-359-8083; E-mail: email@example.com.Our work did not receive any financial support. Allauthors declare no conflict of interests.AbstractBackground. Neuropathic pain (NP) is a very fre-quent and unrecognized condition in clinical prac-tice. Therefore, it is important to have a reliableinstrument to assess pain subtypes in variouscultures. The Leeds Assessment of NeuropathicSymptoms and Signs (LANSS) has been widelyused and validated in many countries. Up to now,there has been no reliability study of this instru-ment in Brazil.Methods. The scores of the Brazilian Portugueseversion of the LANSS were studied in a sample of 90chronic pain outpatients from southern Brazil.LANSS was translated into Portuguese and thenback translated to English. Intraclass correlationcoefficient (ICC) and internal consistency (IC) wereestimated. The intensity of pain complaints, otherdemographic data, and LANSS scores distributionaccording to pain subtypes (nociceptive, neuro-pathic, and mixed) were also evaluated.Results. The Brazilian Portuguese version of theLANSS showed good ICC (r = 0.97) and IC (Cron-bachs a = 0.67 for total LANSS score). Patients withNP provided significant higher LANSS scores(19.1 3.3) in comparison with those with nocicep-tive (7.3 4.5) and mixed (13.9 3.7) types of pain.Conclusions. This LANSS version was found tobe a reliable instrument for the evaluation of paincomplaints due to a variety of causes. The profile ofpain scores was similar to that observed in othercountries.Key Words. Brazilian Portuguese Validation; Neuro-pathic Pain; Nociceptive Pain; LANSSIntroductionNeuropathic pain (NP) is defined as pain initiated by alesion or dysfunction of the somatosensory system as aresult of abnormal activity of the nociceptive pathway[1,2]. Distinguishing nociceptive pain from NP is not onlyan academic issue . This is important for the establish-ment of etiology, prognosis, and specific therapeutic strat-egies for chronic pain. However, this is not an easy task inclinical practice as the poorly myelinated fibers involved inNP are not detectable by conventional nerve conductionstudies . Apart from that, verbal descriptors for NP arequite imprecise. Recently, several assessment tools havebeen developed to aid in the diagnosis of NP .Among the above-mentioned tools, the Leeds Assess-ment of Neuropathic Symptoms and Signs (LANSS) painscale is probably the easiest one to be used in clinicalpractice . This scale proposes the use of the terms suchas pain of predominant neuropathic or pain of predomi-nant nociceptive types  as the coexistence of neuro-pathic and nociceptive pain is frequent in the samepatient.The pattern of painful symptoms may differ among variousethnic and cultural groups; therefore, it is important tohave a reliable instrument to assess pain complaints invarious settings. The LANSS scale has been validated forseveral languages, such as Spanish  and Turkish .Pain Medicine 2011; 12: 15441550Wiley Periodicals, Inc.1544However, no parameters of validation have been pub-lished for a Brazilian Portuguese version of LANSS yet.This study aimed to evaluate the intraclass correlationcoefficient (ICC) and internal consistency (IC) of the Bra-zilian Portuguese version of the LANSS scale and also toassess the capability of the Brazilian LANSS version indiscriminating different types of pain.MethodsA cross-sectional study was conducted in a sample ofchronic pain patients selected by consecutive referrals tothe Neuromuscular and Rheumatology Clinics of Hospitalde Clnicas de Porto Alegre, Brazil. The diagnosis of NPwas done through clinical and laboratorial criteria , i.e.,diabetic neuropathy or postherpetic neuralgia. Nocicep-tive pain was considered when there was clinical and/orlaboratorial evidence of nonneural tissue damage, i.e.,osteoarthritis (positive X-ray plus swollen joints) or myo-fascial pain (compatible history with presence of triggerpoints) and with normal electrophysiological studies.Patients with mixed types of pain were those with bothneural and nonneural tissues involved, i.e., radiculopathyor carpal tunnel syndrome. Eligibility criteria also includedage more than 18 years, Portuguese native speaker fromBrazil, and having chronic pain, defined as pain of morethan 3 months in duration.The original English versions of the LANSS scale wastranslated into Brazilian Portuguese by two Portuguesenative speakers who work in the area of neurology and areboth fluent in English. Those neurologists adapted someexpressions according to cultural Brazilian peculiarities.Subsequently, the Brazilian Portuguese version was backtranslated into English by an English native speaking phy-sician who has been living in Brazil for the past 3 years.Final adaptations were carried out further to ensure fullcultural and educational comprehension, and this versionwas sent to the original author (MIB) for corrections (seefinal Portuguese version in Appendix 1).The LANSS scale consists of a total of seven items includ-ing a five-item questionnaire regarding pain symptomsand two items involving sensory tests for the presence ofallodynia and decreased sensation to pinprick [6,14]. Forpinprick testing, a 23-gauge needle was supported in asyringe barrel perpendicularly placed in contact with thepatients skin for several times so that only the mass couldexert downward pressure and not the examiner. Hyperal-gesia was judged to be present when pinprick testingelicited an exaggerated painful response at the index sitecompared with the control site. Allodynia was also judgedto be present when pain was elicited by gently stroking apiece of cotton wool over the index site and when normalsensation was experienced in the control site.Responses to the items were a yes or no type and wereweighted differently depending upon the question.Responses are then summed to calculate a total scorefrom 0 to 24. Scores below 12 suggested pain with noci-ceptive predominance, whereas scores above 12 sug-gested pain with neuropathic predominance.Additionally, we also noted demographic variables, as wellas visual analog scale for pain intensity (VAS-INT) andvisual analog scale for impact on activities of daily living(VAS-ADL) in the last 2 months. The study was approvedby the Ethic Committee for Medical Research of the Hos-pital de Clnicas de Porto Alegre. All patients signed aninformed consent before being enrolled into the study.ProcedureThe interviews followed the same structure and scoringmethods described in the original English versions , andthey were performed twice by two trained and indepen-dent neurologists. The evaluators (PS and VFT) were blindto the disease of the patient and to the results of LANSSscores obtained by each other. The interviews were madewith an interval of at least 1 day between them.Data Reduction and Statistical AnalysesDescriptive statistics (mean, standard deviation, and fre-quency) were calculated for demographic data andLANSS scores. The patients were grouped into three:those with nociceptive, neuropathic, and mixed types ofpain. LANSS scores were then compared using ANOVAfollowed by Bonferronis test. Correlation coefficients wereestimated for the ICC on the total LANSS, and IC wasanalyzed by Cronbachs a coefficient. A P value The Pearson coefficient correlation was 0.89 (P = 0.01) forthe total LANNS scores between the assessment of twoindependent evaluators. Indeed, there were no differencesregarding the mean LANSS score between the first andsecond interviews (12.8 6.5 vs 12.6 6.8; Studentst-test; P = 0.6).DiscussionOur study of the Brazilian Portuguese version of theLANSS has demonstrated that is a reliable instrument.Indeed, both ICC and Cronbachs coefficient were asgood as those obtained by Spanish  and Turkish groups. We also found that NP is one of the most dis-abling types of pain in terms of the impact on the activitiesof daily living in comparison with nociceptive and mixedsubtypes, and this illustrates the importance of an accu-rate diagnosis of pain.Distinguishing NP from nociceptive pain is difficult forseveral reasons . First, the perception of NP is purelysubjective, which means that despite the use of the mostsophisticated equipment, NP intensity cannot be mea-sured. Second, in contrast to other sensory systems, thepain system is not static, but on contrary, it changes in adynamic and somewhat unpredictable fashion wheneverthe system is activated. Third, signs and symptoms of NPmay change during the course of the disease if it becomeschronic. Finally, neuropathic and nociceptive mechanismsmay coexist, and the clinician must decide whether neu-Table 1 Pain classification based on etiology (number of patients in parenthesis)Neuropathic Pain (34) Mixed Pain (12) Nociceptive Pain (44)Polyneuropathies (21) Diabetic (9) Infectious (9) Alcohol (1) Drug induced (1) Idiopathic (1)Trigeminal neuralgia (3)Postherpetic neuralgia (2)CRPS I (2)CRPS II (2)Traumatic nerve injury (2)Phantom limb (1)Idiopathic plexopathy (1)Radiculopathy (8)Entrapment (4)Osteoarthrosis (18)Myofascial (15)Low back pain (4)Rheumatoid arthritis (3)Ankylosing spondylitis (1)Plantar fasciitis (1)Gout (1)Bursitis (1)CRPS = complex regional pain syndrome; HIV = human immunodeficiency virus.Table 2 Demographic data according to pain classificationNociceptive (N = 44) Mixed (N = 12) Neuropathic (N = 34) PAge (ys) 55.5 14.2 48.7 10.6 54.0 12.0 0.2Weight (kg) 71.7 14.7 77.1 11.7 73.1 15.0 0.5Height (cm) 165.4 9.8 170.5 7.2 168.2 9.5 0.1Education (year) 8.7 3.3 6.9 3.1 9.4 3.7 0.1VAS-INT (010) 6.7 2.2 6.9 2.5 7.6 1.5 0.1VAS-ADL (010) 5.9 2.6 6.8 2.5 7.5 2.1 0.03VAS-ADL = visual analog scale for impact on activities of daily living; VAS-INT = visual analog scale for pain intensity.Figure 1 LANSS scores according to painclassification.1546Schestatsky et al.ropathic mechanisms predominate in the patients overallpain experience . Therefore, when diseases or disor-ders are dominated by subjective symptoms, and theassociated clinical signs are few or absent, the require-ment for diagnostic screening tools becomes crucial.One of the advantages of screening tools, such as theLANSS scale, is that they can also be used by nonspe-cialists, and this is important because the estimatedprevalence of NP can reach 8% in the general population. As they are very easy to use by both clinicians andpatients, these instruments are very attractive becausethey provide immediate and reliable information. However,pain descriptors themselves cannot make the diagnosisby themselves  and, indeed, screening tools do notidentify about 1020% of patients with NP . If patientswith NP are detected, clinicians should then undertakefurther assessment [18,19], which might affect subse-quently diagnostic and therapeutic approaches .In clinical practice, sometimes patients with nociceptivepain can be misdiagnosed as having NP . In our study,for instance, several patients with clear musculoskeletaldisorders answered yes to question number 5 address-ing burning sensation. Indeed, burning sensation is notdiscriminative of NP [6,15] and can also be present inpatients with osteoarthritis. Therefore, according to theLANNS scale, such a descriptor received low weight forsupporting the NP diagnosis. Sometimes, low-level edu-cation subjects can misinterpret questions regardingsensory symptoms . In our study, however, there wereno significant differences in years of education betweengroups, reflecting the lack of influence of education levelsfor pain diagnosis using the LANSS.The LANSS scale was able to differentiate patients withneuropathic, nociceptive, and mixed types of pain. This isvery important for clinical studies of analgesic drugs. Inclu-sion in trials of patients with mixed pain, instead of NP,would usually be inappropriate and could explain the usualrefractoriness of NP drugs . It is important to stress thatNP and other types of pains are often present in the samepatient and that LANSS can help in identifying such con-ditions. The coexistence of different types of pain caninfluence the results of drug trials; i.e., patients with mixedpain may not respond to antiepileptic drugs as much aspatients with pure NP. For example, as Backonja pointedout , patients with diabetic neuropathy affecting thedistal legs may also have some inflammatory pain fromdiabetic ulcer, and this could explain the reason why ananti-NP drug is refractory in some cases of painful diabeticneuropathies. In the same way, Treede et al.  recom-mend that more stringent criteria should be used in drugtrials than those used in epidemiological studies. Indeed,its inclusion in trials involving patients with possible, ratherthan definitive or probable, NP, i.e, LANSS scores below20 points, would be inappropriate for the assessment ofdrug efficacy.In the last few years, many common diseases and intakeof drugs have been linked with NP because of small fiberlesions, such as human immunodeficiency virus infection, prediabetes , hypothyroidism , alcoholism, hyperlipidemia , statin , and metformin use. Indeed, the most common cause of polyneuropathy,the chronic idiopathic axonal form, is recognized by smallfiber affectation and NP in the early phases of a disease. Therefore, because chronic pain is also verycommon in the general population, the use of LANSScould also help to diagnose such conditions in clinicalpractice. For instance, patients with chronic pain andhigh LANSS scores should be more carefully watchedand investigated.The LANSS scale application has received some criti-cism regarding methodological concerns, especiallyabout the safety of the pinprick test . Differentlyfrom Dr. Backonja and Dr. Krauses experience , wedid not have any skin bleeding episodes during the23-gauge needle examination in our 90 patients, in thesame way as Bennetts  and other authors [12,13]experiences. In any case, a 23-gauge needle used in theLANSS assessment can be alternatively replaced by 1-gmonofilaments  in patients with thin and fragile skinsuch as the elderly or in patients with complex regionalpain syndrome.Our study has some limitations. First, our sample size wasonly of moderate size, and it was drawn from only oneclinic, which may limit the ability to generalize the findingsto all settings. However, we adapted carefully the LANSSfor the patients understanding. Also, we used two asses-sors instead of only one, who were blind to each othersfindings, and this contributed to the strength of our work.Second, we did not include other important clinicalparameters such as impact of pain on sleep and quality oflife. However, the VAS-ADL could have been roughly pro-vided similar information. Third, we retested patients in arelatively short period of time, and this could have induceda memory bias to the LANSS answers. However, if longerintervals of retesting were used, progression or regressionof the disease may have been seen, compromising the ICof our results.In conclusion, the Portuguese version of the LANSS scalefrom Brazil is reliable for use in clinical practice andresearch. This is an important achievement because theinformation taken from the LANSS is vital to understandthe distribution, etiology, and natural history of NP.AcknowledgmentThe authors would like to thank Vnia Naomi Hirakata,statistician of the Hospital de Clnicas de Porto Alegre.References1 Merskey H, Bogduk N, eds. Classification of ChronicPain. Descriptions of Chronic Pain Syndromes andDefinitions of Pain Terms. Seattle, WA: IASP Press;1994:20912.1547Validation of the LANSS Scale for Brazilian Portuguese Language2 Treede RD, Jensen TS, Campbell JN, et al. Neuro-pathic pain: Redefinition and a grading system forclinical and research purposes. Neurology2008;70:16305.3 Schestatsky P, Nascimento OJ. What do general neu-rologists need to know about neuropathic pain? ArqNeuropsiquiatr 2009;67:7419.4 Schestatsky P, Gerchman F, Valls-Sol J. Neurophysi-ological tools for small fiber assessment in painful dia-betic neuropathy. Pain Med 2009;10:601.5 Galer BS, Jensen MP. 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Neuropathic pain indiabetes, prediabetes and normal glucose tolerance:The MONICA/KORA Augsburg Surveys S2 and S3.Pain Med 2009;10:393400.24 rstavik K, Norheim I, Jrum E. Pain and small-fiberneuropathy in patients with hypothyroidism. Neurology2006;67:78691.25 Koike H, Mori K, Misu K, et al. Painful alcoholic poly-neuropathy with predominant small-fiber loss andnormal thiamine status. Neurology 2001;56:172732.26 McManis PG, Windebank AJ, Kiziltan M. Neuropathyassociated with hyperlipidemia. Neurology 1994;44:21856.27 Lo YL, Leoh TH, Loh LM, Tan CE. Statin therapy andsmall fibre neuropathy: A serial electrophysiologicalstudy. J Neurol Sci 2003;208:1058.28 Wile DJ, Toth C. Association of metformin, elevatedhomocysteine, and methylmalonic acid levels andclinically worsened diabetic peripheral neuropathy.Diabetes Care 2010;33:15661.1548Schestatsky et al.29 de Schryver EL, van Schelven LJ, Notermans NC, deValk HW, Oey PL. Small-fibre neuropathy can bedetected in patients with chronic idiopathic axonalpolyneuropathy. Eur J Neurol 2011;18:10035.30 Backonja MM. Need for differential assessment toolsof neuropathic pain and the deficits of LANSS painscale. Pain 2002;97:22934.31 Backonja MM. Need for differential assessmenttools of neuropathic pain and the deficits of LANSSpain scale (comment letter). Pain 2002;98:22930.32 Bennett M. Need for differential assessment tools ofneuropathic pain and the deficits of LANSS pain scale(author reply). Pain 2002;98:23031.Appendix 1: Portuguese Version from Brazil of LANSS ScaleNome: __________________________Data: ____________________________Esta escala de dor ajuda a determinar como os nervos que carregam a informao de dor esto funcionando. importante obter este tipo de informao, pois ela pode ajudar na escolha de um tratamento especfico para o seu tipode dor.A. QUESTIONRIO DE DOR Pense na dor que voc vem sentindo na ltima semana. Por favor, diga se qualquer uma das caractersticas abaixo se aplica a sua dor. Responda apenas SIM ou NO.1. A sua dor se parece com uma sensao estranha e desagradvel na pele? Palavras do tipo agulhadas, choqueseltricos e formigamento so as que melhor descrevem estas sensaes.a. NOMinha dor no se parece com is . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. SIMEu tenho este tipo de sensao com freqncia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. A sua dor faz com que a cor da pele dolorida mude de cor? Palavras do tipo manchada ou avermelhada ou rosadadescrevem a aparncia da sua pele.a. NOMinha dor no afeta a cor da minha pele . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. SIMEu percebi que a dor faz com que minha pele mude de cor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. A sua dor faz com a pele afetada fique sensvel ao toque? A ocorrncia de sensaes desagradveis e/ou dolorosasao toque leve ou mesmo ao toque da roupa ao vestir-se descrevem esta sensibilidade anormal.a. NOMinha dor no faz com que minha pele fique mais sensvel nesta rea . . . . . . . . . . . . . . . . . . . . . . . . . b. SIMMinha pele mais sensvel ao toque nesta rea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. A sua dor inicia de repente, sem nenhuma razo aparente, quando voc est parado? Palavras tipo choqueseltricos, dor em pontada ou dor explosiva descrevem estas sensaes.a. NOMinha dor no sentida desta forma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. SIMEu tenho estas sensaes com muita freqncia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5. A sua dor faz com que a temperatura da sua pele na rea dolorida mude? Palavras tipo calor e queimaodescrevem estas sensaes.a. NOEu no tenho este tipo de sensao . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. SIMEu tenho estas sensaes com freqncia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . B. EXAME DA SENSIBILIDADE: A sensibilidade da pele pode ser examinada comparando-se a rea dolorida com a reacontralateral ou nas reas adjacentes no-doloridas avaliando a presena de alodinia e alterao do limiar desensao ao estmulo da agulha (LSA).6. ALODINIA: Examine a resposta ao toque leve com algodo sobre a rea no-dolorida e, a seguir, na rea dolorida.Caso sensaes normais forem percebidas no lado no-dolorido e, ao contrrio, se dor ou sensaes desagradveis(sensao tipo picada ou latejante) forem percebidas na rea afetada, ento a alodinia est presente.a. NOSensao normal em ambas as reas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. SIMAlodinia somente na rea dolorida . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1549Validation of the LANSS Scale for Brazilian Portuguese Language7. ALTERAO DO LIMIAR POR ESTMULO DE AGULHA (LEA)a. Determine o LEA atravs da comparao da resposta a uma agulha de espessura 23 (cor azul) conectada auma seringa de 2 mLsem a parte internasuavemente colocada nas reas doloridas da pele e depois nasno-doloridas.b. Caso uma sensao de agulhada normal for sentida na rea da pele no-dolorida, mas uma sensao diferentefor sentida na rea dolorida como, por exemplo nenhuma sensao ou somente sensao de toque (LEAaumentado) ou dor muito intensa (LEA diminudo), isso significa que h um LEA alterado.c. Caso a sensao de agulhada no for percebida em nenhuma rea, conecte a parte interna da seringa agulhapara aumentar o peso e repita a manobra.a. NOSensao igual em ambas reas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. SIMLimiar por estmulo de agulha alterado no lado dolorido . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ESCORE:Some os valores entre parnteses nos achados descritivos e de exame da sensibilidade para obter um escore globalESCORE TOTAL (mximo 24): ________________Se o escore < 12, mecanismos neuropticos so improvveis de estarem contribuindo para a dor do paciente.Se escore 12, mecanismos neuropticos provavelmente esto contribuindo para a dor do paciente.1550Schestatsky et al.