|Year : 2019 | Volume
| Issue : 2 | Page : 57-60
Screening of probable neuropathic pain in patients with diabetes in Derna, Libya
Raga A Elzahaf1, Oasma A Tashani2
1 Department of Public Health, College of Medical Technology, Derna, Libya; Middle East and North African Research Group, Leeds Beckett University, Leeds, UK
2 Middle East and North African Research Group; School of Clinical and Applied Sciences, Leeds Beckett University, Leeds, UK
|Date of Web Publication||24-Jun-2019|
Dr. Raga A Elzahaf
Department of Public Health, College of Medical Technology, Derna
Source of Support: None, Conflict of Interest: None
Background: Neuropathic pain (NeP) is one of the most frequent complications of diabetes. There is a need to obtain data about the prevalence of NeP among patients with diabetes in Libya to plan appropriate national pain management strategies. Aim: The aim of this study is to estimate the prevalence of NeP in patients with diabetes and to determine the demographic factors associated with NeP. Methods: The linguistically validated Arabic version of the Self-completed Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) questionnaire was used to screen for probable NeP. Patients with diabetes were asked to fill the questionnaire while in the diabetic center from May 2015 to October 2015. Pain intensity was measured using a visual analog scale. Results: A total of 418 patients (mean ± standard deviation [SD] of age = 56.8 ± 11.8 years) participated in this study with more women (n = 248, 59.3%) taking part than men (n = 170, 40.7%). The overall prevalence of probable NeP among patients with diabetes in this sample, classified as S-LANSS positive with a score of ≥12, was estimated to be 28.5% (95% confidence interval = 24.3%–32.9%). The proportion of females in participants with NeP was 33.5%. The mean pain intensity ± SD was 5.67 ± 2.96. No statistically significant difference was found between different age groups with regard to the presence of NeP. Conclusion: NeP is a common complication associated with diabetes in Derna, Libya. There is a need to improve the assessment and management of NeP in this population.
Keywords: Diabetes, Libya, neuropathic pain, screening, self-completed leeds assessment of neuropathic symptoms and signs
|How to cite this article:|
Elzahaf RA, Tashani OA. Screening of probable neuropathic pain in patients with diabetes in Derna, Libya. Libyan J Med Sci 2019;3:57-60
| Introduction|| |
The prevalence of diabetes mellitus increased worldwide mainly due to lifestyle changes and an increased prevalence of obesity. Research to date has mostly focused on the prevalence of diabetes in developed countries with only a few studies reporting the prevalence of the disease and its complications in the developing world. The available evidence suggests that the prevalence of diabetes in the Middle East and North African region (MENA) ranged from 4% in Somalia to 21% in Kuwait. Kadiki and Roaeid estimated the prevalence of diabetes mellitus in Libya as 14.1% (95% confidence interval = 10.9–17.1). In a recent systematic review, it was found that the prevalence of diabetes across Northern African countries ranged from 2.6% in rural Sudan to 20% in urban Egypt. The main causes of diabetes in North Africa are changes to the nature of diets, lack of physical activity, and an aging population.
However, less is known about the prevalence of complications of diabetes in the MENA region. One of the most significant complications of the disease is neuropathies, whether this is with or without pain. Neuropathic pain (NeP) arises as a direct consequence of a lesion or disease of the somatosensory system. Screening for NeP in diabetes is important because it is a complex type of pain, which is very difficult to diagnose and manage. Recently, the prevention, detection, and treatment of NeP in diabetes have received attention in the developed world; however, there has been little published information on the prevalence of NeP among diabetics in the MENA region. The aim of this study is to estimate the prevalence of NeP in Derna, Libya as an example of the MENA region. This was achieved by surveying the presence or absence of NeP among Libyan adult patients with diabetes attending outpatient clinics in the city of Derna using symptoms based on a validated questionnaire that was developed originally in English and then linguistically validated in Libya on a sample of chronic pain. In addition, risk factors associated with NeP in these patients will also be investigated.
| Methods|| |
A cross-sectional study of randomly selected patients with diabetes from one center in the eastern coastal city of Derna (population estimated at 120,000) filled a purpose-designed questionnaire to obtain information on demographic characteristics, personal and family medical history, the duration and treatment of diabetes, hypertension, and cigarette smoking.
The validated Arabic version of the Self-completed Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) questionnaire was used to screen for NeP. Patients with diabetes were asked to fill the questionnaire while in the diabetic center from May 2015 to October 2015.
Pain intensity was measured using a visual analog scale of 100 mm anchored by no pain at 0 mm and the most severe pain at 100 mm.
The local research ethics committee in the faculty of medical technology approved the study and all patients participating in the study gave written informed consent.
All data analysis was conducted using the Statistical Package for the Social Sciences version 20.0 (IBM, Ottawa, Canada). The data were summarized using frequency tables, means, and standard deviations (SD) for continuous variables. The Chi-square test was used to make a comparison among categorical variables. The level of statistical significance was considered as P < 0.05.
Univariate odds ratios (OR) were estimated for each demographic factor to compare between different groups categorized as having probable NeP (scored more or equal to 12 on S-LANSS) or not having NeP (scored than 12 on S-LANSS). A logistic regression model was also used to calculate the same odds ratio (OR) adjusted for sex and age. When there was more than one group in any category, for example, age groups, a reference group was chosen in line with those used in previous studies. As the Arabic S-LANSS was not tested before for convergent (S-LANNS score is correlated with pain intensity) or discriminant validity (S-LANSS score is not correlated with unrelated variables such as age), the data obtained in this study were used to determine these two criteria by calculating Spearman correlation matrices, to inform the discussion.
| Results|| |
A total of 418 patients (mean ± SD of age = 56.8 ± 11.8 years) participated in this study with more women (n = 248, 59.3%) taking part than men (n = 170, 40.7%) [Table 1]. The overall prevalence of probable NeP among patients with diabetes was estimated to be 28.5% (95% confidence interval [CI] = 24.3% to 32.9%) in this population; classified as S-LANSS positive with a score of ≥12.
|Table 1: Prevalence of probable neuropathic pain and odd ratios of having neuropathic pain according to gender, age, and marital status|
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No statistically significant difference was found between different age groups with regard to the presence of NeP. However, the prevalence of NeP was higher (38.8%) in the 61–70 years of age group.
The proportion of females in respondents with NeP was 33.5%. NeP was significantly more common in females than males (χ2 = 7.84 [P = 0.006], OR = 1.87 [1.19–2.94]). Some epidemiological studies have investigated marital status to reflect on the social status which might or might not affect patients' lifestyle which in turn affects their control of blood sugar. This is specifically related to diet habits. No statistically significant difference was found between married and unmarried respondents in having NeP [Table 1].
Respondents with hypertension were found to be more likely to have NeP than their nonhypertensive counterparts (χ2 = 11.13, P = 0.001, OR = 2.07; 95% CI = 1.34–3.19). No statistically significant difference was found between smokers and nonsmokers in the sample surveyed (χ2 = 3.83, P = 0.050).
The prevalence of NeP was higher in those with family history of diabetes (χ2 = 6·6, P = 0.010, OR = 1.77, 95% CI = 1.14–2.75). About 84.7% of the diabetes patients had type 2 diabetes [Table 2]. However, the prevalence of NeP among type 1 and 2 was not significantly different (χ2 = 3.5, P = 0.06, OR, 0.53; 95% CI = 0.27–1.03). The mean pain intensity of the whole sample was 5.67 ± 2.96, and the pain intensity was significantly (P = 0.0001) higher in patients with NeP than in those without NeP characteristics (χ2 = 16.45, P = 0.0001, OR = 2.71, 95% CI = 1.65–4.43).
|Table 2: Univariate odds ratios for the association of neuropathic with specific medical history diagnoses in patients studied to evaluate the prevalence of neuropathic pain|
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Participants who reported that they have ≥10 years' experience with diabetes were more likely to report NeP than those with <10 years' duration of diabetes; however, these differences were not statistically significant [OR = 1.13; 95% CI = 0.73–1.75, χ2 = 0.333, P = 0.56, [Table 2].
The convergent validity of the Arabic S-LANSS for patients with diabetes with NeP was moderate at r = 0.4, P = 0.001, and its discriminant validity was high as there was no significant correlation between the total score and age as a continuous variable (r = 0.03).
| Discussion|| |
The current cross-sectional study found the prevalence of NeP among patients with type 1 or type 2 diabetes attending outpatient clinics in Derna, Libya to be 28.5% (95% CI = 24.3%–32.9%), using the S-LANSS questionnaire. This questionnaire is easy to use to assess probable NeP and does involve sensory testing, but it is not a substitute to full clinical examination. It has, however, been translated and culturally adapted for use on chronic pain patients in Libya. Its convergent validity in this group of patients was moderate, suggesting a need to investigate its measurement properties. Although we argue that using the S-LANSS questionnaire or similar tools could suggest a possible diagnosis of NeP and therefore increase the likelihood of referral of these patients to pain specialists to improve the management of their pain. To the best of our knowledge, there are no guidelines of the management of NeP in this unit, or the country at large.
The estimated prevalence of this study was higher than the prevalence of NeP among diabetics in France, which was found to be 20.3% (95% CI = 17.4–23.1) using the DN4 questionnaire and higher than the prevalence of NeP among type 2 diabetics in Brazilian patients; found to be 16.7% by Cortez et al. using the same questionnaire. Based on a recent systematic review of NeP associated with diabetes, which includes five studies (7898 participants), the overall prevalence of painful diabetic neuropathy in people with diabetes from the MENA region was 43.2%. However, Libya was not surveyed before the publication of this systematic review for painful diabetic neuropathy. A very recent study estimated that painful diabetic neuropathy in Benghazi, Libya is 42.2%. The high prevalence of NeP among Libyan diabetics may be due to poor control of diabetes.
In contrast to studies on non-MENA populations, the current study found that females are more likely to report NeP pain than males while Bouhassira et al. and Cortez et al., found no statistically significant differences between men and women in the prevalence of NeP.
In this study, it was found that there are no statistically significant differences between type 1 and type 2 and while NeP was more common in type 2 diabetics, this may have been because of the small number of type 1 diabetics in the sample. This is different from the results of the studies in Brazil and France, which found that patients' diagnosis with type 2 diabetes was associated with NeP.,
Our study has some limitations. The data were collected from one city in Libya, and therefore results are only representative of the study area and cannot be applied to the entire population. As with all screening tools, without full clinical examination, the results can only suggest the likelihood of the presence of NeP, and hence, it was denoted as probable NeP. Another limitation was that the reference age group sample size was 6 and therefore, all the OR of other groups may be slightly affected. However, when the age was divided into two categories at the cut point of 60 years, the adjusted OR of the old group (>60 years) for having Nep was 13.5 with reference to the young group suggesting again age and duration of diabetes were the main predictor of NeP. The last limitation was that other causes and risk factors of NeP (such as Vitamin B12 deficiency, hypothyroidism, and specific types of medications) were not assessed and a further study into investigating these factors is needed.
| Conclusion|| |
NeP is a common complication associated with diabetes in Derna, Libya. The main finding suggested a high rate of NeP as assessed by S-LANSS patient survey. There is a need to improve the assessment and management of NeP in this population.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]