Development of neuropathic pain screening tool in isiZulu

Fagbohun, Temitope Richard
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Neuropathic pain is a subjective experience that affects the mechanism of the somatosensory system positively (paresthesias, spontaneous pain, increased sensation of pain) or negatively. It has a debilitating effect on the cognitive, emotional, and physical function of the patients. There has not been an effective diagnosis of this type of pain, hence poor prognosis by pain experts. Indeed, there is a need for an effective diagnostic tool for neuropathic pain quality that will differentiate it from non- neuropathic pain. Several neuropathic pain screening tools (Neuropathic Pain Scale (NPS), Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), Douleur Neuropathique en 4 Questions (DN4), PainDETECT Questionnaire (PDQ)) has been developed and validated in the description of pain symptoms and clinical signs; and translated in different languages. Neuropathic pain has been a challenging type of pain managed by pain experts and has created a burden to the patients, family of the patients and government. Several neuropathic pain diagnoses procedures have been suggested in the past, but this has not been effective in management of this type of pain. Recently, the combination of verbal and clinical testing of the patient has brought up a good diagnosis prognosis and improved the management of neuropathic pain. This has led to development and validation of several translated tools (NPS, LANSS, ID Pain, DN4) in different local languages applicable to the test populations. None of these tools have been developed in African languages to be applicable in Africa to diagnose neuropathic pain. Therefore, in this study, neuropathic pain screening tool was conducted in IsiZulu (an official language in South Africa) speaking population attending the University of Witwatersrand hospitals (Rahima Moosa Mother and Child Hospital, Helen Joseph Hospital, Chris Hani Baragwanath Hospital and Charlotte Maxeke Academic Hospital Johannesburg, South Africa) between April 2015 and July 2019. Firstly, we conducted a systematic review on the psychometric properties, reliability, and validity of translated version of DN4, LANSS and Pain DETECT. The outcome showed that all the translated versions of the screening tools had a good sensitivity, specificity, reliability and validity ranging from 70%-100%. Secondly, a neuropathic pain screening tool in isiZulu was developed from the translated DN4 version. In a sample population of 122 participants (neuropathic n = 61; nociceptive n = 61), patients were asked to describe their pain in isiZulu and the triggers thereof. Neuropathic pain was distinguished from nociceptive by location of the origin and aetiology of the patients’ pain. This was recorded and transcribed to English language by professional translators. ’Burning‘ symptom (29%) was frequently described spontaneously by neuropathic pain patients followed by cramping (25%) and sharp pain (17%) symptoms. However, stabbing (2%) was less frequently described during the spontaneous description. Furthermore, a published copy of prompt neuropathic pain symptoms in isiZulu was read to them to identify the symptoms they were experiencing. Tingling was never mentioned as a symptom during the spontaneous description. Nevertheless, it was only after the prompt symptoms were read out in isiZulu language that the patients were able to identify tingling (61%) as a more frequent symptom they were experiencing. Lastly, the isiZulu neuropathic pain screening tool was developed to identify patients with neuropathic pain describing their pain as ‘pulling’, ‘cramping’ and ‘cutting’, symptoms in conjunction with clinical signs (Hypoesthesia to pin-prick, brush and touch). This new tool was translated by the professional translator directly to isiZulu language. A pilot study was conducted at chronic pain clinics (rheumatoid arthritis clinic and orthopaedic clinic). Only participants with pure nociceptive (n=23) or neuropathic pain (n=23) were included in this study. Patients with mixed pain were excluded in the study. Two clinicians rated the pain of the patients independently. The result shows that the new tool had an accuracy of 89.0%, sensitivity 83%, specificity of 94.0%, positive predictive value 90.0% and negative predictive value 88.0% compared to the original DN4 English version. This clearly indicates the new neuropathic pain screening tool in isiZulu is reliable to distinguish neuropathic from non-neuropathic pain patients. In conclusion, the data presented has projected insight on the importance of a translated version of screening tools to be useful in the clinical settings for distinguishing neuropathic from non-neuropathic pain in isiZulu speaking population in South Africa. All these have added new and unique knowledge in the clinical frontiers
A thesis submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Doctor of Philosophy, 2021