03. (종설) hwp

종설 https://doi.org/10.17340/jkna.2021.2.18 손은희김병준 a 충남대학교병원신경과, 성균관대학교의과대학삼성서울병원신경과 a Clinical Scale for Neuropathic Pain Eun Hee Sohn, MD, Byoung Joon Kim, MD a Department of Neurology, Chungnam National University Hospital, Daejeon, Korea Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea a Neuropathic pain caused by a lesion or disease of the somatosensory nervous system is underdiagnosed and difficult to treat. Questionnaires based on self-reported symptoms have improved diagnosis and management of neuropathic pain. Visual analog scale and numeric rating scale are most well-known unidimensional pain questionnaires. Multidimensional questionnaire or specialized questionnaire for neuropathic pain are more useful to diagnose neuropathic pain. Screening questionnaires help to identify neuropathic pain easily, and assessment questionnaires make it possible to create phenotypic profiles of neuropathic pain and determine an efficacy of management. J Korean Neurol Assoc 39(2 suppl):24-36, 2021 Key Words: Pain, Neuralgia, Questionnaire, Scale 서 론 만성통증은발병기전에따라통각통증 (nociceptive pain) 과신경병통증 (neuropathic pain) 으로구분할수있다. 1 통각통증은조직의손상, 외상, 염증등에의해발생하는통증으로정상감각신경계를통해전달된다. 관절염이나힘줄염, 외상에의한통증이대표적이며, 조직을보호하는중요한역할을한다. 이와달리신경병통증은감각신경계의손상이나질환으로발생하는통증으로대상포진후신경통, 당뇨병말초신경병에동반된통증등이대표적이다. 1,2 신경병통증은비정상적통증으로, 수면장애나우울증을유발하여삶의질을저하시킨다. 약물이나중재시술로신경병통증을치료하지만, 아직까지만족할만한치료법이없으며, 치료에도불구하고만성화되는경우가많아초기에신경병통증을진단하고치료를시작하는것이중요하다. 따라서만성통증을호소하는환자에서신 Received September 28, 2020 Revised December 18, 2020 Accepted December 18, 2020 Address for correspondence: Byoung Joon Kim, MD Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea Tel: +82-2-3410-2379 Fax: +82-2-3412-3422 E-mail: bjkim@skku.edu 경병통증의동반여부를확인하여적절히치료하는것이중요하다. 신경병통증의진단을위해서는우선신경병통증이동반되었는지확인하는과정이필요하며, 환자가작성하는설문지나검사자의인터뷰를통해동반여부와통증양상을파악한다. 현재까지통증과관련된다양한설문지가개발되어있으며, 신경병통증을진단하기위해서는통증평가설문지와신경병통증에특화된설문지를사용하고있다. 통증평가설문지는한가지증상에대해정량평가하는단순평가설문지 (unidimensional pain questionnaire) 와통증을포함한다양한증상에대해평가하는다면평가설문지 (multidimensional pain questionnaire) 가있다. 3 신경병통증에특화된설문지는크게선별검사설문지 (screening questionnaire) 와평가설문지 (assessment questionnaire) 로구분할수있다. 4 대개의만성통증환자는신경병통증과통각통증이혼재되어있는경우가많기때문에만성통증환자에서신경병통증동반여부를파악하기위해선별검사설문지를사용하며, 신경병통증의치료효과를판단하기위해평가설문지를사용한다. 24 대한신경과학회지제 39 권제 2 호부록 1, 2021

본론 1. 통증평가설문지 1) 단순평가설문지단순평가설문지는통증의정도를환자가표시하게하는가장단순한방법으로이해하기쉽고수행하는시간이오래걸리지않으므로빠르게통증의정도를판단하기에좋은방법이다. 그러나통증의정도외에여러가지다양한통증의양상이나빈도등다른정보를알지못하는단점이있고, 환자가한번보고하는것에의존하므로신뢰도가떨어질수있는단점이있다. (1) 시각통증등급 (Visual Analogue Scale, VAS) VAS는길이가정해진선위에통증의정도를환자가스스로표시하도록하는방법이다 (Appendix 1). 3 100 mm 선을긋고, 선의시작부분은 통증이전혀없는상태 이고 100 mm 끝부분은 상상할수있는가장심한통증 으로가정하여현재통증이얼마나심한지선위에표시하도록하여통증의정도를측정한다. 선의시작부분부터환자가표시한부분까지길이를측정하여길이가 0-4 mm 이내인경우는통증이없는상태, 5-44 mm는경미한통증, 45-74 mm는중등도통증, 75-100 mm는심한통증으로판독하기도한다. 5 VAS를수행하기위해서는훈련을할필요가없고간편하게할수있는장점이있지만, 인지기능이떨어지는환자에서는검사의신뢰도가떨어지고전화로시행할수없는단점이있다. (1) 맥길통증척도설문지 (MPQ) MPQ는현재또는지난 1주일간의평균적인통증에대해검사자가환자에게인터뷰를통해시행하는설문지이다. 통증을자세하게표현하기위해아래의여러영역별설문항목이있다. 1) 통증의부위를신체그림에표시하고, 2) 통증의양상을감각 (sensory), 감정, 평가 (evaluative) 그리고기타 (miscellaneous) 의 4개의하위범주로구분하여각각범주에맞는증상을나열하여확인하며, 3) 통증의정도를범주형으로표시한다. 8 MPQ는통증의양상을다양한용어로표현함으로써통증의양과질을적절히평가하며, 관절통을포함한다양한통증에서신뢰도가입증되었다. 9,10 또한신경병통증의양상을표현하는용어가많이포함되어있어신경병통증과통각통증의구별에도도움을준다. 3 그러나사용하는용어가많아서시간이오래걸리며, 환자가용어를이해할수있도록설명이필요하다는단점이있다. (2) 단축형맥길통증척도설문지 (Short-Form McGill Pain Questionnaire, SF-MPQ) SF-MPQ는용어가너무많은 MPQ의단점을보완하기위해감각범주에서 11개의용어와감정범주에서 4개의용어를뽑아각각의심한정도를확인하고, 전체통증의정도를측정하도록고안되었다. 11 2009년에는신경병통증을감별하기위해신경병통증에해당하는 7개의항목을추가하여총 22항목을 0-10까지수치로척도화하도록한 SF-MPQ-2 가고안되었다. 12 다양한통증을유발하는질환과여러언어에서유용성이입증되었으며, 13,14 SF-MPQ 한국어판도신뢰도가입증되어있다 (Appendix 2). 15 (2) 수치통증척도 (Numerical Rating Scale, NRS) NRS는 VAS를수치화하여 0-10까지숫자로표현한것이다 (Appendix 1). 즉환자에게 0은 통증이전혀없는상태 이고 10은 상상할수있는가장심한통증 으로가정하도록하여현재통증의정도를숫자로말하도록한다. 6 만성통증환자들에서 NRS가이해하기쉽고수행하기쉬워 VAS보다더선호한다는연구결과가있었다. 7 또한 NRS는말로표현할수있기때문에전화를이용한설문조사에서사용할수있는장점이있다. 2) 다면평가설문지통증의정도뿐만아니라통증의위치와양상, 정동 (affect) 등의다양한면을평가할수있도록고안된설문지이다. 여러가지설문지가고안되었으나, 맥길통증척도설문지 (McGill Pain Questionnaire, MPQ) 가신경병통증에가장널리사용되고있다. 2. 신경병통증설문지신경병통증은자극없이가만히있는상태에서발생하는자발통증 (spontaneous pain) 과자극에의해발생하는유발통증 (evoked pain) 으로나타날수있다. 자발통증은저리다, 찌릿하다, 따끔거린다, 화끈거린다, 시리다, 둔하다, 아프다등의다양한말로표현하며, 16 계속지속되기도하지만간헐적혹은돌발적으로나타날수도있다. 유발통증은기계적 (mechanical) 자극, 차갑거나뜨거운온도자극에의해유발되는통증으로통각과민 (hyperalgesia) 이나무해자극통증 (allodynia) 으로나타난다. 따라서신경병통증을진단하고정도를평가하기위한설문지는이런다양한증상의정도와통증부위, 빈도등을확인하도록구성되어있다. J Korean Neurol Assoc Volume 39 No. 2 Supplement 1, 2021 25

손은희김병준 1) 선별검사설문지대부분의신경병통증설문지는선별검사를위해개발되었으며, LANSS (Leeds Assessment of Neuropathic Symptoms and Signs), 17 신경병통증설문지 (Neuropathic Pain Questionnaire, NPQ) 18 DN4 (Douleur Neuropathique 4 Questions), 19 ID통증 (ID pain TM Pfizer Inc.), 20 paindetect 21 등이이에해당된다. 선별검사설문지들은모두신경병통증진단에높은민감도 (67-85%) 와특이도 (74-90%) 를보이고있으며, 4 그중 LANSS, DN4와 paindetect (Appendix 3) 가세계여러나라에서주로사용되고있다. 22 선별검사설문지는다양한증상에대한내용과신체진찰로이루어져있으며, 서로중복되는항목이있으므로목적에맞는적절한설문지를선택하여사용하도록한다 (Table 1). 선별검사설문지를사용하면비통증전문가도복합통증환자에서신경병통증을쉽고빠르게발견할수있는장점이있는반면, 신체진찰이포함되지않거나적게포함되어있어설문지만으로는진단의정확도가떨어지는단점이있다. 따라서선별검사설문지를시행하여신경병통증이동반되었음이의심되는환자는신경계진찰을시행하여신경의손상여부를확인하는것이필요하다. 또한선별검사설문지는특정부위의통증에국한해서설문조사를하므로전신에퍼져있는통증의정도를판단하지못하고, 삼차신경통진단에는사용할수없는단점이있다. 4 2) 평가설문지신경병통증을임상양상에따라분류하고치료에대한반응을판단하기위해평가설문지를사용한다. 과거발병기전에따라신경병통증을치료하려던시도는발병기전을밝히기어려워서실패하였고, 최근에는임상양상에따라신경병통증환자를분류하여이에맞는치료를하려는시도가이루어지고있다. 임상양상에따 Table 1. Components of screening and assessment questionnaires for neuropathic pain Questionnaire Screening Assessment LANSS NPQ DN4 ID pain paindetect NPS NPSI Symptoms reported Spontaneous symptoms Prickling, tingling, pins & needles + + + + + + + Electric shocks, shooting + + + + + + + Hot or burning + + + + + + + Numbness + + + + Painful cold or freezing pain + + + Dull, squeezing + + + Evoked by Light touching + + + + + + Mild pressure + + Heat or cold + + Change in weather + Itching + + + Pain limited to joints - Temporal patterns + + + Radiation of pain + Autonomic change + Physical examination Brush allodynia + + Raised soft touch threshold + pinprick thresholdraised + + The minus sign (-) indicates items that reduce the score. LANSS; Leeds Assessments of Neuropathic Symptoms and Signs, NPQ; Neuropathic Pain Questionnaire, DN4; Douleur Neuropathique 4 Questions, NPS; Neuropathic Pain Scale, NPSI; Neuropathic Pain Symptom Inventory. 26 대한신경과학회지제 39 권제 2 호부록 1, 2021

라신경병통증환자를분류하기위해서는다양한증상에대한평가가필요하며, 이를위해서신경병통증의평가설문지와정량감각검사 (quantitative sensory testing) 를시행한다. 신경병통증척도 (Neuropathic Pain Scale, NPS) 23 와신경병통증증상목록 (Neuropathic Pain Symptom Inventory [NPSI]) 24 이평가설문지로개발되어신뢰도가입증된대표적인예이다. 이들은선별설문지와유사한증상을평가하고있으나무감각 (numbess) 과같은음성증상 (negative symptom) 에대한평가를하지않는단점이있다 (Table 1). paindetect는선별검사설문지로개발되었으나여러연구들에서평가설문지로도사용될수있음이입증되었으며, 25,26 한국어번역본의신뢰도도입증되었다. 27 SF-MPQ-2는신경병통증뿐만아니라다양한통증에서평가를위한설문지로널리알려져있다. 3) 한국어신경병통증설문지 (Korean Neuropathic Pain Questionnaire, KNPQ) 국내다기관신경과연구자들이모여 2012년 LANSS, 17 NPQ, 18 DN4, 19 ID통증, 20 NPS 23 와 NPSI 24 를한글로번역하고중복되는항목은삭제하여총 25문항으로구성된 KNPQ를개발하였다 (Table 2, Appendix 4). 28 신경병통증과비신경병통증으로나뉘는환자 120명을대상으로 KNPQ를시행하여 KNPQ의신뢰도를확인하였고, 각항목중신경병통증의선별검사에유용한항목과평가에유용한항목을모아추가설문지를제작하였다. 이후 KNPQ를이용한후속연구는없어추가연구가필요한상태이지만, 신경병통증의선별과평가를위해한국어로신뢰도가입증된유용한설문지로생각된다. Table 2. KNPQ items from 4 screening tools and 2 rating scales KNPQ item LANSS item NPQ item DN4 item ID pain item NPS item NPSI item 1 1 3 5 1 2 11 2 6 3 4 5 3 4 5 4 5 1 1 2 3, 10-2 a 1 5 8 2 5, 10-2 a 6 4, 10-1 b 7 7 10-1 b 2 8 10-1 b 3 9 6 11 10 5 8 10 9 11 10 12 6 4 12 13 7 4 6 3 14 8 15 9 16 7 7 17 3 2 6 18 2 19 1 20 9 9 21 10 22 12 23 24 4 25 7 KNPQ; Korean Neuropathic Pain Questionnaire, LANSS; Leeds Assessment of Neuropathic Symptoms and Signs, NPQ; Neuropathic Pain Questionnaire, DN4; Douleur Neuropathique 4 Questions, NPS; Neuropathic Pain Scale, NPSI; Neuropathic Pain Symptom Inventory. NPS item 10 consists of 2 subunits (10-1 b and 10-2 a subitems). J Korean Neurol Assoc Volume 39 No. 2 Supplement 1, 2021 27

손은희김병준 결 론 신경병통증은다양한증상으로나타나며, 다른통증과복합되어나타나는경우가흔하므로만성통증환자에서신경병통증을찾아내고적절히치료하는것은중요하다. VAS와 NRS는빠른시간내에통증의정도를파악할수있는장점이있지만, 그외의정보는알수없는단점이있다. 다양한증상을확인하고통증정도를파악하기위해서는 SF-MPQ 같은다면평가척도가필요하다. 만성통증을호소하는환자에서신경병통증혼재여부를확인하기위해 LANSS, DN4, paindetect와같은선별검사설문지를활용하고, 신경병통증이의심되는경우병력청취와신경계진찰을통해신경병통증을되도록빨리진단하는것이통증조절에중요하다. 신경병통증을적절히치료하기위해서임상양상에따른분류가도움이되므로 NPS나 NPSI 같은신경병통증평가설문지를시행하여임상양상에따라통증을분류할수있으며, 또한평가설문지는치료전후를비교하여치료의효과를판단하는데에도움을줄수있다. paindetect는신경병통증의선별검사와평가에모두사용할수있으며, 한국어로번역되어신뢰도가입증된설문지이다. KNPQ는여러가지를한국어로번역하고조합하여신경병통증의선별과평가를위해개발된임상척도로, 한국인의신경병통증진단과치료에유용할것으로생각된다. 본원고에서소개한한국어판설문지인 SF-MPQ, paindetect, KNPQ는개인적으로환자진료를위해사용시허가를받거나사용요금을내지않아도되므로임상진료에도움이될것으로생각된다. Acknowledgements 이논문은 2005년대한신경과학회지별책으로발간된 ' 근신경계질환임상척도 에게재된종설을개정보완한것이다. REFERENCES 1. Interantional Association for the Study of Pain (IASP). IASP Terminology. [online] [cited 2017 Dec 14]. Available from: URL:https://www.iasppain.org/terminology?navItemNumber=576#Neuropathicpain. 2. McCarberg B, D'Arcy Y, Parsons B, Sadosky A, Thorpe A, Behar R. Neuropathic pain: a narrative review of etiology, assessment, diagnosis, and treatment for primary care providers. Curr Med Res Opin 2017;33:1361-1369. 3. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: visual analog scale for pain (VAS pain), numeric rating scale for pain (NRS pain), McGill pain questionnaire (MPQ), short-form mcgill pain questionnaire (SF-MPQ), chronic pain grade scale (CPGS), short form-36 bodily pain scale (SF-36 BPS), and measure of intermittent and constant osteoarthritis pain (ICOAP). Arthritis Care Res (Hoboken) 2011;63 Suppl 11:S240-S252. 4. Attal N, Bouhassira D, Baron R. Diagnosis and assessment of neuropathic pain through questionnaires. Lancet Neurol 2018;17:456-466. 5. Jensen MP, Chen C, Brugger AM. Interpretation of visual analog scale ratings and change scores: a reanalysis of two clinical trials of postoperative pain. J Pain 2003;4:407-414. 6. Rodriguez CS. Pain measurement in the elderly: a review. Pain Manag Nurs 2001;2:38-46. 7. de Williams AC, Davies HTO, Chadury Y. Simple pain rating scales hide complex idiosyncratic meanings. Pain 2000;85:457-463. 8. Melzack R. The McGill pain questionnaire: major properties and scoring methods. Pain 1975;1:277-299. 9. Papageorgiou AC, Badley EM. The quality of pain in arthritis: the words patients use to describe overall pain and pain in individual joints at rest and on movement. J Rheumatol 1989;16:106-112. 10. Gandhi R, Tsvetkov D, Dhottar H, Davey JR, Mahomed NN. Quantifying the pain experience in hip and knee osteoarthritis. Pain Res Manag 2010;15:224-228. 11. Melzack R. The short-form McGill pain questionnaire. Pain 1987;30: 191-197. 12. Dworkin RH, Turk DC, Revicki DA, Harding G, Coyne KS, Peirce-Sandner S, et al. Development and initial validation of an expanded and revised version of the short-form McGill pain questionnaire (SF-MPQ-2). Pain 2009;144:35-42. 13. Dworkin RH, Turk DC, Trudeau JJ, Benson C, Biondi DM, Katz NP, et al. Validation of the short-form McGill pain questionnaire-2 (SF-MPQ-2) in acute low back pain. J Pain 2015;16:357-366. 14. Hasvik E, Haugen AJ, Haukeland-Parker S, Rimehaug SA, Gjerstad J, Grøvle L. Cross-cultural adaptation and validation of the norwegian short-form McGill pain questionnaire-2 in low back-related leg pain. Spine (Phila Pa 1976) 2019;44:E774-E781. 15. Choi SA, Son C, Lee JH, Cho S. Confirmatory factor analysis of the Korean version of the short-form McGill pain questionnaire with chronic pain patients: a comparison of alternative models. Health Qual Life Outcomes 2015;13:15. 16. Boureau F, Doubrère JF, Luu M. Study of verbal description in neuropathic pain. Pain 1990;42:145-152. 17. Bennett M. The LANSS pain scale: the Leeds assessment of neuropathic symptoms and signs. Pain 2001;92:147-157. 18. Krause SJ, Backonja MM. Development of a neuropathic pain questionnaire. Clin J Pain 2003;19:306-314. 19. Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain 2005;114:29-36. 20. Portenoy R. Development and testing of a neuropathic pain screening questionnaire: ID pain. Curr Med Res Opin 2006;22:1555-1565. 21. Freynhagen R, Baron R, Gockel U, Tölle TR. paindetect: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin 2006;22:1911-1920. 22. Bouhassira D, Attal N. Diagnosis and assessment of neuropathic pain: the saga of clinical tools. Pain 2011;152:S74-S83. 23. Galer BS, Jensen MP. Development and preliminary validation of a pain measure specific to neuropathic pain: the neuropathic pain scale. Neurology 1997;48:332-338. 28 대한신경과학회지제 39 권제 2 호부록 1, 2021

24. Bouhassira D, Attal N, Fermanian J, Alchaar H, Gautron M, Masquelier E, et al. Development and validation of the neuropathic pain symptom inventory. Pain 2004;108:248-257. 25. Keller T, Freynhagen R, Tölle TR, Liwowsky I, Möller P, Hüllemann P, et al. A retrospective analysis of the long-term test-retest stability of pain descriptors of the paindetect questionnaire. Curr Med Res Opin 2016;32:343-349. 26. Packham TL, Cappelleri JC, Sadosky A, MacDermid JC, Brunner F. Measurement properties of paindetect: Rasch analysis of responses from community-dwelling adults with neuropathic pain. BMC Neurol 2017;17:48. 27. Sung JK, Choi JH, Jeong J, Kim WJ, Lee DJ, Lee SC, et al. Korean version of the paindetect questionnaire: a study for cultural adaptation and validation. Pain Pract 2017;17:494-504. 28. Yun DJ, Oh J, Kim BJ, Lim JG, Bae JS, Jeong D, et al. Development of Korean neuropathic pain questionnaire for neuropathic pain screening and grading: a pilot study. J Korean Neurol Assoc 2012;30:15-25. J Korean Neurol Assoc Volume 39 No. 2 Supplement 1, 2021 29

손은희김병준 Appendix 1. Scales on a single dimension Visual Analog Scale (VAS) Instruction: Mark on the line below the amount how strong your pain is right now. No pain at all The worst pain imaginable Numeric Rating Scale (NRS) Instruction: Choose a number from 0 to 10 which indicates how strong your pain is right now. No pain at all 0 1 2 3 4 5 6 7 8 9 10 The worst pain imaginable Adapted from Hawker et al. 3 with permission of John Wiley and Sons. Appendix 2. Short-Form McGill Pain Questionnaire (SF-MPQ) A. 지난한주동안당신이느낀통증양상을표시해주시기바랍니다. 각항목당한개의칸에만표시해주시기바랍니다. 전혀없음 약한통증 중간정도의통증 심한통증 욱신거리는 0 1 2 3 쿡쿡쑤시는 0 1 2 3 찌르듯이아픈 0 1 2 3 날카로운양상의 0 1 2 3 뒤틀리듯이아픈 0 1 2 3 갉아먹는듯이아픈 0 1 2 3 화끈거리는 0 1 2 3 아리는 0 1 2 3 뻐근한 0 1 2 3 누르면아픈 0 1 2 3 쪼개지듯이아픈 0 1 2 3 피곤하고기진맥진한 0 1 2 3 ( 구역질나게 ) 메스꺼운 0 1 2 3 그런통증을다시겪는다고생각하기만해도겁나는 0 1 2 3 통증이있을때는마치내가벌을받고있는것같이비참한 0 1 2 3 B. 지난한주동안느꼈던당신의통증정도를 ( ) 표시해주세요. 0 1 2 3 4 5 6 7 8 9 10 상상가능한가장심한통증 C. 현재느끼는당신의통증강도에대해표시해주세요. 0 (no pain) 1 약한정도의통증 (mild) 2 불편한혹은불쾌한정도의통증 (discomfort) 3 괴로운정도의통증 (distressing) 4 고통스러운정도의통증 (horrible) 5 극도로심하게고통스러운통증 (excruciating) SF-MPQ-2 R. Melzack and the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT), 2009. 30 대한신경과학회지제 39 권제 2 호부록 1, 2021

Appendix 3. paindetect 주된통증부위를표시하십시오. 통증이신체다른부분으로퍼집니까? 예 아니오 예인경우, 통증이퍼지는방향을그려주십시오. 지금현재귀하의통증이어느정도라고평가하시겠습니까? 0 1 2 3 4 5 6 7 8 9 10 없음 최대 지난 4주간가장심한통증이얼마나심했습니까? 0 1 2 3 4 5 6 7 8 9 10 없음 최대 지난 4주간통증이평균적으로얼마나심했습니까? 0 1 2 3 4 5 6 7 8 9 10 없음 최대 귀하의통증경과를가장잘설명하는그림에표시하십시오. 약간의기복이있는지속적인통증 통증발작이있는지속적인통증 통증발작사이에는통증이없음 통증발작사이에통증이있음 J Korean Neurol Assoc Volume 39 No. 2 Supplement 1, 2021 31

손은희김병준 Appendix 3. Continued 표시한부위에타는듯한느낌 ( 예 : 쏘는통증 ) 이있습니까? 통증부위에저리거나따끔거림 ( 개미가기어가는듯하거나전기로인해찌릿함 ) 을느끼십니까? 이부위에가볍게닿으면 ( 옷, 담요 ) 통증을느끼십니까? 통증부위에전기충격과같은갑작스러운통증발작이있습니까? 차가움또는열 ( 목욕물 ) 로인해이부위에종종통증을느끼십니까? 표시한부위가무감각합니까? 이부위를약간눌러도 ( 예 : 손가락으로 ) 통증이있습니까? 통증설문조사채점 전혀없음거의없음약간중간정도심함매우심함 합산한점수 / 총 35 점 표시한통증양상및통증퍼짐에따라다음숫자를가감하십시오. 이를다합하여최종점수를계산하십시오. 약간의기복이있는지속적인통증 통증발작이있는지속적인통증 표시된경우, 또는 통증발작사이에는통증이없음 통증발작사이에통증이있음 표시된경우, 또는 표시된경우 통증퍼짐? 표시된경우 최종점수 32 대한신경과학회지제 39 권제 2 호부록 1, 2021

Appendix 3. Continued 최종점수 없음불분명있음 신경병증성통증가능성이적음 (<15%) 결과가확실하지않으나, 신경병증성통증가능성이있음 신경병증성통증가능성이큼 (>90%) Adapted from Sung et al. 27 with permission from Pfizer. J Korean Neurol Assoc Volume 39 No. 2 Supplement 1, 2021 33

손은희김병준 Appendix 4. 한국어신경병통증설문지 (Korean Neuropathic Pain Questionnaire, KNPQ) 지난일주일동안느낀통증의감별과평가를위한질문들입니다. 질문에해당하는통증이없는경우에는 0 에표시하시고, 통증이있는경우그정도를해당하는숫자에표시해주세요. 1. 핀이나바늘로찌르듯따끔거리는통증입니까? 2. 칼이나송곳으로후벼파는듯한통증입니까? 3. 전기오듯이찌릿찌릿한통증입니까? 4. 화끈거리는통증입니까? 5. 시린통증입니까? 6. 뻐근하거나묵직한통증입니까? 7. 꽉죄는듯한통증입니까? 8. 눌리는듯한통증입니까? 34 대한신경과학회지제 39 권제 2 호부록 1, 2021

Appendix 4. Continued 9. 통증부위가가볍게닿아도통증이유발되거나악화됩니까? 10. 누르면통증이유발되거나악화됩니까? 11. 차가운것이닿으면통증이유발되거나악화됩니까? 12. 피가안통할때처럼저리는통증입니까? 13. 통증부위가치과에서마취한듯남의살같거나감각이둔합니까? 감각둔함없음 전혀감각을느끼지못함 14. 통증부위가벌레가기어가는듯하거나가렵습니까? 가려움없음 상상할수있는최대가려움 15. 통증부위를만지면더아프게 ( 예민하게 ) 느껴집니까? 예민함없음 상상할수있는최악의예민함 16. 통증부위의피부색깔이정상부분과다릅니까? 다르지않음 완전히다름 J Korean Neurol Assoc Volume 39 No. 2 Supplement 1, 2021 35

손은희김병준 Appendix 4. Continued 17. 통증의정도가얼마나심합니까? 18. 통증때문에얼마나힘들거나불편합니까? 불편하지않음 상상할수있는최악의불편한통증 19. 평소견딜수없이아파서통증때문에일상생활에지장을받습니까? 지장없음 상상할수있는최악의일상생활지장 20. 날씨에따라통증이심해집니까? 심해지지않음 상상할수있는최대로심해짐 21. 통증이관절에만있습니까? 예 / 아니오 22. 지난 24 시간동안저절로발생한통증이얼마나오랫동안지속되었습니까? ( ) 1 지속적으로 2 8 시간 ~12 시간미만 3 3 시간 ~8 시간미만 4 1 시간 ~3 시간미만 5 1 시간미만 23. 지난 24 시간동안통증이얼마나자주발생하였습니까? ( ) 1 21 회이상 2 11 회 ~20 회 3 6 회 ~10 회 4 1 회 ~5 회 5 통증이없었다 24. 지난일주일동안느끼신통증을느낀대로표현해주세요. ( 예 : 화닥거린다, 우리하다등 ) Adapted from Yun et al. 28 with permission. 36 대한신경과학회지제 39 권제 2 호부록 1, 2021