Non‐Cyclical Mastalgia as a Central Sensitization Component: Implications for Multidisciplinary Treatment Approaches

Neuropathic pain screening tools have shown promise in identifying common neuropathic pain characteristics that derive from diverse etiologies (e.g., diabetic peripheral neuropathy, postherpetic neuralgia). However, no prior studies have specifically assessed whether these tools are capable of discerning the underlying pain mechanisms in the vast, heterogeneous group of patients diagnosed with failed back surgery syndrome (FBSS). In this clinical observational study, two tests for neuropathic pain characteristics, the Douleur Neuropathique en 4 (DN4) and Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) questionnaires, were performed on 43 subjects with FBSS. Subjects underwent physical or neurosensory exam components of the DN4 and LANSS in the region of most severe pain (e.g., axial low back or lower extremities). DN4 and LANSS scores were correlated with clinical history and neurologic exam, pain-related quality of life questionnaires, and compared to an independent assessment of pain distribution. The presence of neuropathic characteristics, determined by the DN4 (62% sensitivity, 44% specificity), LANSS (38% sensitivity, 75% specificity; cut-offs of 4 and 12, respectively), or their combination (20% sensitivity, 58% specificity) was associated with higher pain intensity as measured by the visual analog scale (DN4 > 4, P = 0.001; LANSS ≥ 12, P = 0.042), modified Brief Pain Inventory-Short Form (DN4 > 4, P = 0.001; LANSS ≥ 12, P = 0.082), and Neuropathic Pain Symptom Inventory (DN4 > 4, P = 0.001; LANSS ≥ 12, P = 0.001), and greater pain-related functional impairment as measured by the Roland-Morris Disability Questionnaire (DN4 > 4, P = 0.006; LANSS ≥ 12, P = 0.018). The percentage of subjects characterized as neuropathic by the DN4 and LANSS lacked concordance (67.4 vs. 25.6), and the distribution of most severe symptoms (i.e., axial vs radicular) did not correlate with subjects determined to have neuropathic pain. Unlike other neuropathic syndromes, the neuropathic component of FBSS is less reliably identified by the LANSS and DN4.

ObjectiveThe aim of the study was to investigate the relationship between the presence of neuropathic pain assessed by the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scale and electrophysiological findings in patients with carpal tunnel syndrome (CTS).MethodsWe studied 124 hands with idiopathic CTS with pain complaints involving hand and wrist. All hands were assessed by the LANSS with which a score of 12 or more is defined as pain dominated by neuropathic mechanisms. These hands were assigned to minimal, mild, moderate, severe, or extreme severe groups according to the results of the median nerve conduction studies.ResultsA LANSS score ≥ 12, suggestive of pain dominated by neuropathic mechanisms, was defined in 59 (47.6%) CTS hands. Pain intensity was significantly higher in CTS hands with a LANSS score ≥ 12 (P < 0.001). Among electrophysiological findings, compound muscle action potential amplitude was significantly lower in hands with a LANSS score ≥ 12 compared with hands with a LANSS score < 12 (P = 0.020). Severity of CTS was not significantly different between LANSS ≥ 12 and LANSS < 12 groups. Electrophysiological severity was significantly higher in CTS hands with evoked pain (P = 0.005) and allodynia (P < 0.001) in LANSS subscore analysis.ConclusionWe suggest that the presence of pain dominated by neuropathic mechanisms in CTS is not related to electrophysiological CTS severity. Neuropathic pain should be assessed carefully in patients with CTS, and an appropriate treatment plan should be chosen, taking into account the clinical and electrophysiological findings together with the true pain classification.

Objectives: This study reports on the effect of Korean medicine treatment, including Soeumin &lt;i&gt;Bojungikgitang-gagambang&lt;/i&gt;, on a patient with postherpetic neuralgia.Methods: The patient received Korean herbal medicine, pharmacopuncture treatment, and acupuncture treatment for 22 days. We assessed changes in symptoms due to the treatment using the Numeric Rating Scale (NRS), the McGill Pain Questionnaire-Short Form (SF-MPQ), and the European Quality of Life-5 Dimensions (EQ-5D) scale. We also measured the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) to distinguish neuropathic pain.Results: After treatment, the patient showed decreased NRS, SF-MPQ, and EQ-5D scores.Conclusion: The results indicate that Korean medicine treatment, including Soeumin &lt;i&gt;Bojungikgitang-gagambang&lt;/i&gt;, is an effective management of symptoms in patients with postherpetic neuralgia.

Central sensitivity syndrome (CSS) comprises various symptoms caused by central sensitisation (CS). Using the central sensitisation inventory (CSI), a screening questionnaire developed for detecting CSS, this syndrome was recently identified in patients with long-standing rheumatoid arthritis (RA). However, the descriptors of CS-related pain and the effects of CSS on symptoms in patients with rheumatoid arthritis (RA) remain unknown. We examined the characteristics of pain and influence of CSS on patient and evaluator global assessment among multiple clinical variables. We used the central sensitisation inventory (CSI) and short-form McGill pain questionnaire to evaluate CSS and characteristics of pain in 240 outpatients with RA. Disease activity, fibromyalgia, neuropathic pain, anxiety, depression, pain catastrophising, and health-related quality of life were evaluated. We used multivariate analysis to analyse the characteristics of CS-related pain according to CSI and the effect of CSS on patient global assessment (PGA), evaluator global assessment (EGA), and PGA minus EGA among relevant clinical variables. In patients with RA, the main descriptors of pain according to severity of CSI scores were "sharp" and "stabbing", whereas those of pain according to disease activity were "tender" and "throbbing". CSS was associated with EGA (p=0.000, β=- 0.199) and PGA minus EGA (p=0.021, β=0.147), but not with PGA. In patients with RA, descriptors for CS-related pain differ from those for disease activity-related pain. CSS may have an important impact on EGA and PGA minus EGA. Additionally, CSI may be helpful in identifying why there is discordance between PGA and EGA.

The process of pain recovery varies and can include the recovery, maintenance, or worsening of symptoms. Many cases of patients with pain show a tendency of recovering as predicted; however, some do not. The characteristics of cases that do not fit the prediction of pain recovery remain unclear. We performed cluster and decision tree analyses to reveal the characteristics in cases that do not fit the prediction of pain recovery. A total of 43 patients with musculoskeletal pain (nonoperative: 22 patients, operative: 13 patients) and central pain (brain disease: 5 patients, spinal cord disease: 3 patients) were included in this longitudinal study. Central sensitivity syndrome (CSS) outcome measures (Central Sensitisation Inventory), pain intensity-related outcome measures (Short-Form McGill Pain Questionnaire-2 (SFMPQ-2)), and cognitive-emotional outcome measures (Hospital Anxiety and Depression Scale and Pain Catastrophising Scale-4) of all patients were assessed at baseline and after 1-2 months. Regression analysis was used to calculate pain recovery prediction values. A hierarchical cluster analysis based on the predicted change of SFMPQ-2 and the observed change of SFMPQ-2 was used to extract subgroups that fit and those that do not fit pain recovery prediction. To extract the characteristics of subgroups that do not fit the prediction of pain recovery, a decision tree analysis was performed. The level of significance was set at 5%. In the results of cluster analysis, patients were classified into three subgroups. Cluster 1 was characterised by worse pain intensity from baseline, cluster 2 by pain, having recovered less and mildly than the predicted value, and Cluster 3 by a marked recovery of pain. In the results of the decision tree analysis, the CSI change was extracted as an indicator related to the classification of all clusters. Our findings suggest that the poor improvement of CSS is characteristic in cases that do not fit the prediction of pain recovery.

Factors That Affect the Number of Tender Points in Fibromyalgia and Chronic Widespread Pain Patients Who Did not Meet the ACR 1990 Criteria for Fibromyalgia: Are Tender Points a Reflection of Neuropathic Pain?

Pain management is crucial in treating chronic conditions, and screening for neuropathic pain is important due to its distinct management compared to nociceptive pain. Simple screening questionnaires play a key role in patient management and clinical research. This study aims to translate and adapt the English version of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale into Bengali, followed by standard validation. The study was conducted in 2 phases. Four independent translators performed forward and backward translations of the English LANSS pain scale into Bengali. The Bengali version was finalized after expert committee reviews and cognitive debriefing. The final validation was carried out among 191 patients with chronic pain. In the last phase, the validity (construct, and discriminant validity) and reliability (interclass item-wise correlation coefficient) of the translated tool were evaluated. The Bengali version demonstrated a high reliability (α = 0.85 and rSB = 0.92). Exploratory factor and confirmatory factor analysis revealed a three-factor structure. ROC analysis showed the highest sensitivity (94.6%) and specificity (93.4%) at a cutoff value of 9.5. Additionally, the agreement between the clinical assessments and the Bengali version of the LANSS pain scale diagnosis indicated almost perfect agreement (κ = 0.84). The Bengali version of the LANSS pain scale exhibits high reliability and validity for assessing neuropathic pain in Bengali-speaking populations.

Diagnosis and treatment of neuropathic pain is an important clinical problem. A self report version of the Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) score provides identification of neuropathic pain without the help and need of a clinician. We targeted validation of the S-LANSS score in the northern Turkish population in this study. For the linguistic validation of S-LANSS, translation and back-translation method was used to adapt S-LANSS into Turkish and a cognitive-debriefing test was performed. A total of 148 patients were enrolled in the present study. S-LANSS, The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), Visual Annalogue Score (VAS) and Neuropathic Pain Questionnaire (NPQ) were performed twice for every patient. The patients were examined and diagnosed as having nociceptive or neuropathic pain by neurologists, who were blind for S-LANSS, LANSS and NPQ scores of the patients. Results of the McNemar test indicated that S-LANSS scores were reliable when the first and the second scores were compared. The sensitivity and specificity of the scale were found to be 98% and 97% respectively. We believe that using S-LANSS scores for the diagnosis of neuropathic pain may help our colleagues as a tool for a quicker differential diagnosis of pain in daily practice.

Pain is a prevalent and complex symptom in neurorehabilitation, with differentiation between neuropathic pain (NP) and musculoskeletal pain (MSK) often proving challenging. This study evaluates the effectiveness of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) and Douleur Neuropathique en 4 Questions (DN4) tools in distinguishing NP from MSK pain, aiming to guide appropriate analgesic selection in a rehabilitation setting. Seventy inpatients undergoing active rehabilitation (32 males, 38 females) aged 18-91 years (mean: 67 years) were assessed using LANSS and DN4 scores over a 2-week period. Prescribed analgesia was recorded and correlated with pain classification based on these scores. The results showed that stroke patients exhibited a higher prevalence of NP, reflected in elevated LANSS and DN4 scores. Spinal cord injury (SCI) patients had the highest total scores, often necessitating dual therapy with pregabalin and amitriptyline. Conversely, patients with fractures had the lowest scores, suggesting predominantly MSK pain, with minimal neuropathic features. Pregabalin was prescribed to 29% of stroke patients but only 6% of fracture patients. In conclusion, LANSS and DN4 effectively identified NP, with DN4 proving easier to interpret. Findings underscore the need for targeted analgesic strategies in neurorehabilitation particularly that of NP in stroke and SCI patients. This is still under-researched in literature, compared to conditions like diabetic neuropathy, and future studies are needed to explore tailored pain management protocols in rehabilitation patients.

Background: Central sensitization (CS) has been held responsible for both persistent pain and high disease activity scores in Spondyloarthritis (SpA). The Central Sensitization Inventory (CSI) is a questionnaire used to determine CS frequency: a score of at least 40 is associated with a high likelihood of CS. Objectives: To investigate the prevalence of CS in our cohort and its association with clinical characteristics of patients and their quality of life. Methods: Adult patients with a diagnosis of Psoriatic Arthritis (PsA) or Axial Spondyloarthritis (AxSpA) who were also classifiable according to ClASsification criteria for Psoriatic Arthritis (CASPAR) and Assessment of SpondyloArthritis international Society (ASAS) criteria respectively, and regularly followed at the SpA outpatient clinic of our Unit were consecutively enrolled from April to November 2023. Their epidemiologic, clinical and clinimetric data were collected, as well as patient-reported outcome measures (PROMs) [CSI, Health Assessment Questionnaire (HAQ), FACIT-Fatigue (FACIT-F), SHORT-FORM 36 (SF-36), and Hospital Anxiety and Depression Scale (HADS)]. Considering the definition of “difficult-to-treat” rheumatoid arthritis, we defined as “multi-failure” those patients who were treated with more than two biologic disease-modifying anti-rheumatic drugs (bDMARDs) with different mechanisms of action. Intergroup comparisons were assessed by using Chi-square, t-test and ANOVA. p-values &lt; 0.05 were considered significant. Results: A total of 100 patients were enrolled, 46 male (46.0%) and 54 female (54.0%), with a mean age of 59.4 ± 9.8 years and a mean disease duration of 14.8 ± 10.1 years; 79 patients (79%) had a diagnosis of PsA and 21 (21%) of AS. Forty-two patients (42.0%) had a CSI score ≥ 40. Significant correlations were found between a CSI score ≥ 40 and female sex (p = 0.004), the occurrence of enthesitis (p = 0.05), DAPSA-CRP (p = 0.02) and ASDAS scores (p = 0.03), a multi-failure condition (p = 0.01), fibromyalgia (FM) (p = 0.004), thyroid disease (p = 0.016) and obesity (p = 0.047). Regarding PROMs, significant correlations were found between CSI and values of HADS (both anxiety and depression), FACIT-F, HAQ and all the domains of SF-36 (p-value &lt; 0.0001). Conclusions: Our data confirmed that more than 40% of SpA patients had CSI values ≥ 40 and underlined how CS could widely impair their disease burden. A routinary evaluation of CS and a multifactorial biopsychosocial perspective in the diagnosis and management of chronic pain in patients with SpA could help rheumatologists in improving their quality of care.

Background: Several studies have described pain prevalence, risk factors, pain and medical variables in spinal cord injury (SCI) populations. In this study on traumatic SCI in Turkey, we surveyed the neuropathic pain experiences during in-patient rehabilitation and defined the relationships between neuropathic pain and demographic and SCI characteristics of patients. Objectives: To survey the neuropathic pain experiences during in-patient rehabilitation in traumatic SCI and to define the relationships between neuropathic pain and demographic and SCI-related characteristics of patients. Study Design: Descriptive study. Setting: Physicial Medicine and Rehabilitation inpatient clinic, Ankara, TUrkey Methods: Sixty-nine SCI patients as inpatients were included in this descriptive study. All patients demographic and SCI-related characteristics were enrolled. The diagnosis of neuropathic pain was made with the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale. Location of pain and pain description, relation to time and severity according to McGill Pain Questionnaire (MPQ) were enrolled. Results: The neuropathic pain localization was below the lesion level in 67 (97.1%) and at the lesion level in 2 (2.9%) patients. The pain was at the hip and leg regions in 36 (52.2%) patients. The neuropathic pain was defined as burning in 27 (39.1%), aching in 26 (37.7%), sharp in 4 (5.8%), stinging in 3 (4.3%), and cramping in 3 (4.3%). We did not find a significant difference between demographic and SCI-related characteristics and the localization of neuropathic pain for the patients (P &gt; 0.05). There was no significant difference according to pain description by MPQ and pain localization (P &gt; 0.05). We found a significant relationship between the patient’s lesion level and the region of pain (P &lt; 0.05). Conclusion: We found the neuropathic pain due to SCI to be mostly below the lesion level with a burning or aching character and we did not find a significant relationship between the demographic and SCI-related characteristics of the patient and the pain characteristics. Key words: Spinal cord injury, pain, neuropathic pain

Objective: The aim of this study was to determine whether a relationship exists between pain questionnaires, diabetic peripheral neuropathy, and the severity of electrophysiological findings. Methods: Patients with diabetes mellitus (DM) whose clinical signs and symptoms were found to be consistent with diabetic neuropathy were included in the present study in Ankara City Hospital Neurology Department between June 2020-January 2021. It was designed as a prospective cross-sectional study. Demographic characteristics, type and duration of DM, the onset of neuropathic complaints, systemic diseases, and DM treatments were noted. Blood tests were performed on all patients. Participants were administered the Douleur Neuropathique 4 Questions (DN4), Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), and Numerical Rating Scale (NRS) questionnaires and an electrophysiological examination. Results: The study included 108 patients. A statistically significant correlation was found between the severity of electrophysiological findings and the age of patients, duration of diabetes, and treatment modality. Additionally, a statistically significant correlation was found between the severity of electrophysiological findings and blood urea nitrogen (BUN) levels and monocyte and platelet counts. According to the NRS, a significant relation was found between BUN values and the severity of pain experienced. The LANSS predicted the severity of electrophysiological findings at a significantly higher accuracy than other questionnaires. Conclusion: Questionnaires can detect diabetic neuropathy, which is mostly asymptomatic, before the onset of DM complications. The LANSS questionnaire reflects the electrophysiological findings severity.

Significant analgesic effects of repetitive transcranial magnetic stimulation (rTMS) have been found in several studies of patients with chronic pain of various origins, but never for malignancy. The objective of this study was to assess the efficacy of 10 sessions of rTMS over the primary motor cortex (M1) in patients suffering from malignant neuropathic pain. Thirty-four patients were randomly allocated into one of two groups to receive real (20 Hz, 10 s, 10 trains with 80% intensity) or sham rTMS daily for 10 consecutive days. Patients were evaluated using a verbal descriptor scale (VDS), a visual analogue scale (VAS), Leeds assessment of neuropathic symptoms and signs (LANSS) and Hamilton rating scale for depression (HAM-D) at baseline, after the first, fifth and 10th treatment sessions, and then 15 days and 1 month after treatment. There were no significant differences between real and sham groups in the duration of illness or pain rating scores at the baseline. A significant 'Time × Group' interaction was recorded indicating that real and sham rTMS had different effects on the VDS, VAS, LANSS and HAM-D scales. Post-hoc testing showed that the group of patients treated with real rTMS had greater improvement in all scales that persisted up to 15 days, but were not present 1 month later. Significant positive correlations between the percentage of pain reduction and HAM-D after the 10th session and 15 days later were recorded. The results demonstrate that 10 rTMS sessions over the M1 can induce short-term pain relief in malignant neuropathic pain.

Neuropathic pain screening questionnaires have limited measurement properties. A systematic review

Objectives This study aims to compare the efficacy of physical therapy (PT) and radial extracorporeal shock wave therapy (rESWT) in the treatment of carpal tunnel syndrome (CTS). Patients and methods Between May 2020 and July 2020, a total of 125 wrists of 95 patients (22 males, 73 females; mean age: 54.3±11.3 years; range, 19 to 69 years) with mild-to-moderate CTS were allocated into three groups and evaluated. The control group (Group 1, n=42) was treated with splinting and an exercise program. Group 2 (n=42) was treated with a total of three sessions of rESWT, splinting and an exercise program. Group 3 (n=41) was treated with a total of 15 sessions of PT modalities, splinting, and an exercise program. Each patient was evaluated before, three weeks and 12 weeks after treatment using a Visual Analog Scale (VAS), the Boston Carpal Tunnel Questionnaire (BCTQ), the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) Pain Scale, and electrodiagnostic testing. Results The reduction in VAS, BCTQ, LANSS, and improvement in sensory nerve conduction velocity were significantly greater at three and 12 weeks of follow-up in Groups 2 and 3, compared to Group 1 (p<0.001). A greater improvement was observed in all clinical parameters in Group 2, compared to Group 3 (p<0.001). Conclusion This is the first study to compare the treatment outcomes of PT and rESWT in the treatment of CTS. The results of this study show that both PT and rESWT are effective in the treatment of CTS; however, rESWT yields superior treatment effects compared to conventional PT. The practicalities of administering rESWT and its efficacy in the treatment of CTS may make it the treatment of choice.