Ep. 18 How to Assess Your Pain
In this episode, Justine and Dan go over a number of different assessments tools you can use to define what types of pain you have, what amplifiers may be playing a role, and how symptoms are affecting you functionally. Besides these validated measures, we'll also introduce our sensitization questionnaire so you can look at the information you pull out through the lens we've been looking at central sensitization through, and finish with a discussion on the impact patient mindset has on the ability to improve. To fill out these questionnaires for yourself, and get additional context and information about them, please visit the episode page at our website below.
Assessments you can take
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Assessments you can take 〰️
The Central Sensitization Inventory (CSI)
The Central Sensitization Inventory (CSI) was developed to identify symptoms associated with Central Sensitization Syndromes (CSSs) and quantify their severity. Here is a detailed history of its development, validation, countries where it has been validated, and the diseases it has been used with:
Development and Validation
The CSI was developed by Mayer et al. (2012) to assess the presence of symptoms related to central sensitization (CS), a proposed mechanism underlying various chronic pain conditions. The initial study demonstrated strong psychometric properties, including test-retest reliability (0.817) and internal consistency (Cronbach's alpha = 0.879)[1][5].
The inventory consists of two parts: Part A includes 25 questions related to common symptoms of CSSs, and Part B asks about previous diagnoses of CSSs. The CSI was validated through factor analysis, which identified four major factors related to somatic and emotional symptoms, accounting for 53.4% of the variance in the dataset[1][5].
Countries of Validation
The CSI has been adapted and validated in several countries, demonstrating its international applicability:
- United States: The original validation studies were conducted in the U.S. with various chronic pain populations[1][5].
- China: A Chinese version of the CSI was validated, showing excellent test-retest reliability and good internal consistency[2].
- Multi-country validation: A study pooled data from multiple countries to assess the dimensionality and reliability of the CSI, confirming its robustness across different cultural contexts[3].
- Other countries: The CSI has been translated and validated in several other languages and regions, including Korean, Russian, and Danish versions, indicating its global use[8].
Diseases and Conditions
The CSI has been used to assess a variety of conditions associated with central sensitization, including:
- Fibromyalgia: Patients with fibromyalgia often report high CSI scores, reflecting the presence of CS-related symptoms[1][5].
- Chronic Widespread Pain: The CSI helps differentiate between fibromyalgia and other chronic pain conditions without fibromyalgia[5].
- Chronic Low Back Pain: The inventory has been usutilized for various CSSs, including irritable bowel syndrome and chronic fatigue syndrome[5][6].
The CSI is a valuable tool for clinicians to identify and assess symptoms related to central sensitization, aiding in the diagnosis and management of related syndromes.
References
1. Mayer, T. G., Neblett, R., Cohen, H., Howard, K. J., Choi, Y. H., Williams, M. J., Perez, Y., & Gatchel, R. J. (2012). The development and psychometric validation of the Central Sensitization Inventory. Pain Practice, 12(4), 276-285.
2. Liang, D., Yu, X., Guo, X., & Zhang, J. (2023). Adaptation and validation of the Chinese version of the Central Sensitisation Inventory in patients with chronic pain. Pain Practice.
3. Cuesta-Vargas, A. I., Neblett, R., Chiarotto, A., Kregel, J., Nijs, J., van Wilgen, C. P., Pitance, L., Knezevic, A., Gatchel, R. J., Mayer, T. G., Viti, C., Roldan-Jiménez, C., Testa, M., Caumo, W., Jeremic-Knezevic, M., & Luciano, J. V. (2018). Dimensionality and reliability of the Central Sensitization Inventory in a pooled multi-country sample. Journal of Pain, 19(3), 317-329.
5. Neblett, R., Hartzell, M. M., Cohen, H., Mayer, T. G., Williams, M., & Gatchel, R. J. (2013). Establishing clinically relevant cutoff scores for the Central Sensitization In…
The DASS-21
The Depression Anxiety Stress Scales (DASS) were developed by Syd Lovibond and Peter Lovibond at the University of New South Wales in 1995. The DASS-21 is a shortened version of the original 42-item scale, designed to efficiently assess the core symptoms of depression, anxiety, and stress over the past week. The development aimed to provide a reliable and valid measure of these emotional states in both clinical and non-clinical settings[3][5].
Validation
The DASS-21 has been extensively validated across various populations, including during the COVID-19 pandemic[4].:
- Internal Consistency: The DASS-21 demonstrates high internal consistency, with Cronbach's alpha values typically above 0.80 for its subscales[2].
- Factor Structure: The scale's factor structure has been validated through confirmatory factor analyses, generally supporting the tripartite model of depression, anxiety, and stress. Some studies have also proposed alternative factor structures, including bifactor models[1][2].
- Cross-Cultural Validity: The DASS-21 has been translated into multiple languages and validated in diverse cultural contexts, including Turkish, Chinese, Bahasa Malay, Persian, and others[1][4].
Countries of Validation
The DASS-21 has been validated in many countries, reflecting its international applicability:
- Australia: As the country of origin, the DASS-21 has been widely used and validated in various Australian populations[5].
- Vietnam: The scale was validated among rural women in northern Vietnam, demonstrating its effectiveness in screening for common mental disorders[1].
- Thailand: It has been validated among Thai populations, including nursing students, highlighting its adaptability to different cultural contexts[7].
- Other Countries: The DASS-21 has been validated in numerous other countries, including the UK, Malaysia, and Greece, among others[1][4].
Diseases and Conditions
The DASS-21 has been employed in assessing psychological distress across a range of conditions:
- Depression and Anxiety Disorders: It is commonly used to screen for and monitor these conditions in both clinical and community settings[2].
- Stress-Related Conditions: The stress subscale is used to evaluate stress levels in various populations, including healthcare workers and students[4].
- Chronic Illness: The DASS-21 is used to assess psychological distress in individuals with chronic illnesses, providing insights into the emotional impact of physical health conditions[4].
References:
1. Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., & Swinson, R. P. (1998). Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychological Assessment, 10(2), 176–181.
2. Lovibond, S. H., & Lovibond, P. F. (1995). Manual for the Depression Anxiety Stress Scales (2nd ed.). Sydney: Psychology Foundation.
3. Chan, R. C. K., & Bernardo, A. B. I. (2017). Translation and Initial Validation of the Depression Anxiety Stress Scales (DASS-21) in Chinese. Psychiatry Research, 251, 85-91.
4. Oei, T. P. S., Sawang, S., Goh, Y. W., & Mukhtar, F. (2013). Using the Depression Anxiety Stress Scale 21 (DASS-21) across cultures. International Journal of Psychology, 48(6), 1018-1029.
5. Bravely. (n.d.). Depression Anxiety and Stress Scale (DASS). Retrieved from https://www.bravely.io/blog/dass
6. Measurely. (n.d.). DASS-21 Overview. Retrieved from https://measurely.com.au/dass-21/
7. NCBI. (n.d.). Validation of depression, anxiety, and stress scales (DASS-21) among Thai nursing students in an online learning environment during the COVID-19 outbreak: A multi-center study. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10312998/
Citations:
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9645756/
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10670895/
[3] https://www.tacklit.com/assessments/depression-anxiety-stress-scales-dass-21
[4] https://measurely.com.au/dass-21/
[5] https://www.bravely.io/blog/dass
[6] https://www2.psy.unsw.edu.au/dass/translations.htm
[7] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10312998/
[8] https://rsdjournal.org/index.php/rsd/article/download/45107/35995/470618
The Pain Detect
The Pain DETECT Questionnaire (PD-Q) is a screening tool developed to identify neuropathic pain components in patients with chronic pain. Here's a summary of its development and validation:
Development
The PD-Q was originally developed in German by Freynhagen et al. in 2006. It was designed to be a simple, patient-completed screening tool that could distinguish neuropathic pain from nociceptive pain without the need for clinical examination[2].
Validation
The PD-Q has undergone extensive validation across various languages and clinical settings:
Cross-Cultural Adaptation
The questionnaire has been translated and validated in multiple languages, including Italian. The Italian version underwent a rigorous translation process, including:
1. Translation from English to Italian
2. Review by bilingual experts
3. Back-translation to English
4. Comparison with the original version
5. Final approval by experts[2]
Psychometric Properties
Internal Consistency: The Italian version of PD-Q demonstrated good internal consistency, indicating that its items reliably measure the same underlying construct[2].
Stability: Test-retest reliability was assessed by administering the questionnaire at baseline and after 24-48 hours, showing good stability over time[2].
Validity: The PD-Q has shown strong construct validity, effectively distinguishing between neuropathic and nociceptive pain in various studies[2][4].
Discriminative Power: The questionnaire has demonstrated excellent ability to discriminate between patients with neuropathic pain and those with nociceptive pain[2][4].
Clinical Applications
The PD-Q has been validated for use in various clinical conditions:
Whiplash-Associated Disorders: A recent study found that the PD-Q showed excellent discriminant validity (AUC ≥ 0.8) in detecting neuropathic pain components in acute whiplash-associated disorders[4].
Musculoskeletal Pain: Research has explored the PD-Q's ability to identify impaired conditioned pain modulation in people with musculoskeletal pain[6].##
Conclusion
The Pain DETECT Questionnaire has been extensively developed and validated as a reliable screening tool for neuropathic pain components. Its cross-cultural adaptations and validations in multiple languages, including Italian, have demonstrated its robustness and applicability across different clinical settings and patient populations.
References:
Freynhagen, R., Baron, R., Gockel, U., & Tölle, T. R. (2006). painDETECT: A new screening questionnaire to identify neuropathic components in patients with back pain. Current Medical Research and Opinion, 22(10), 1911-1920.
Gatti, A., Gentili, M., Baciarello, M., Lazzari, M., Marzi, R., Palombo, E., Sabato, A. F., & Fanelli, G. (2021). Cross Cultural Adaptation and Validation of Italian Version of the Leeds Assessment of Neuropathic Symptoms and Signs Scale and Pain DETECT Questionnaire for the Distinction between Nociceptive and Neuropathic Pain. Pain Research and Management, 2021, 6656917.
Pérez-Cajaraville, J., Carrascosa, A. J., Abejon, D., Ortiz, A., Insausti, J., Ruiz-Huerta, C., & Oteo-Álvaro, A. (2023). Usefulness of the DN4, S-LANSS and painDETECT screening questionnaires to detect the neuropathic pain components in people with acute whiplash-associated disorders: A cross-sectional study. Pain Medicine, 24(12), 1436-1445.
Citations:
[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10339886/
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8102124/
[3] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9275508/
[4] https://pubmed.ncbi.nlm.nih.gov/38150190/
[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10778034/
[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10507948/
[7] https://www.semanticscholar.org/paper/792a75adfc51ef2af3f7c122480a4c0fd0e13291
[8] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11111915/
The Bodily Distress Syndrome (BDS) Checklist
Development
The Bodily Distress Syndrome (BDS) checklist was developed as a self-report measure to assess the most common somatic symptoms associated with functional somatic syndromes. It was designed based on the diagnostic concept of Bodily Distress Syndrome, which aims to provide a unified diagnosis for various functional disorders. The checklist initially included 30 items but was later refined to 25 items, grouped into four symptom clusters: cardiopulmonary, gastrointestinal, musculoskeletal, and general symptoms[1][2].
Validation
The BDS checklist has been validated across different settings and populations:
- Internal Consistency: The checklist demonstrates high internal consistency, with Cronbach's alpha values typically above 0.80, indicating reliable measurement[3][4].
- Factor Structure: Factor analysis has confirmed the four symptom clusters, supporting the construct validity of the checklist[3][5].
- Cross-Cultural Validity: The BDS checklist has been validated in Danish and German populations, among others, demonstrating its applicability across different cultural contexts[2][3].
Countries of Validation
The BDS checklist has been validated in several countries, including:
- Denmark: The checklist was validated in a Danish general population cohort, primary care cohort, and a specialized clinical setting cohort[2][4].
- Germany: The German version of the BDS checklist was validated in a representative German population sample, confirming its reliability and validity in this context[3].
Diseases and Conditions
The BDS checklist has been used to assess bodily distress in various conditions, including:
- Functional Somatic Disorders: It is commonly used to screen for and monitor these conditions in clinical and research settings[2][5].
- Somatic Symptom Disorder: The checklist helps assess somatic symptom burden and illness severity in patients with somatic symptom disorder[3][5].
- Chronic Illness: The BDS checklist is used to evaluate physical symptom burden in individuals with chronic illnesses, providing insights into the impact on health-related quality of life[2][4].
References
1. Budtz-Lilly, A., Fink, P., Ørnbøl, E., Vestergaard, M., Moth, G., Christensen, K. S., & Rosendal, M. (2015). A new questionnaire to identify bodily distress in primary care: The ‘BDS checklist’. Journal of Psychosomatic Research, 78(6), 536-545. https://doi.org/10.1016/j.jpsychores.2015.03.006
2. Petersen, M. W., Schröder, A., Jørgensen, T., Ørnbøl, E., Dantoft, T. M., Eliasen, M., Carstensen, T. W., Falgaard Eplov, L., & Fink, P. (2020). The BDS checklist as measure of illness severity. BMJ Open, 10(12), e042880. https://doi.org/10.1136/bmjopen-2020-042880
3. Schmalbach, B., Roenneberg, C., Hausteiner-Wiehle, C., Henningsen, P., Brähler, E., Zenger, M., & Häuser, W. (2020). Validation of the German version of the Bodily Distress Syndrome 25 checklist in a representative German population sample. Journal of Psychosomatic Research, 128, 109868. https://doi.org/10.1016/j.jpsychores.2019.109868
4. Fink, P., & Schröder, A. (2010). One single diagnosis, bodily distress syndrome, succeeded to capture 10 diagnostic categories of functional somatic syndromes and somatoform disorders. Journal of Psychosomatic Research, 68(5), 415-426. https://doi.org/10.1016/j.jpsychores.2010.02.004
5. Wertenbruch-Rocke, T., Hüsing, P., Löwe, B., & Toussaint, A. (2021). Application and validation of the bodily distress syndrome checklist in a psychosomatic outpatient sample. Journal of Psychosomatic Research, 140, 110251. https://doi.org/10.1016/j.jpsychores.2020.110251
Citations:
[1] https://bjgp.org/content/65/638/e617
[2] https://bmjopen.bmj.com/content/10/12/e042880
[3] https://www.sciencedirect.com/science/article/abs/pii/S0163834320301730
[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7733181/
[5] https://pubmed.ncbi.nlm.nih.gov/33303469/
[6] https://www.sciencedirect.com/science/article/abs/pii/S0022399915000604
The LANSS
The Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale was developed as a tool to identify patients whose pain is predominantly neuropathic in origin. Here are the key details about its development, validation, and international use:
Development
The LANSS pain scale was originally developed in 2001 by Bennett et al. in the United Kingdom. It was created through a two-stage process:
Initial development with 60 chronic pain patients, comparing sensory descriptors and sensory function between those with nociceptive and neuropathic pain.
Derivation of a 7-item scale (5 symptom items and 2 examination items) with a simple scoring system.
Validation
The LANSS was initially validated in a second group of 40 patients, assessing its:
Discriminant ability
Internal consistency
Inter-rater agreement
The original validation found the LANSS to have:
Sensitivity of 82-91%
Specificity of 80-94%
International Validation
The LANSS has been validated in multiple countries and languages, including:
United Kingdom (original English version)
Turkey (Turkish version)
Greece (Greek version)
Portugal (Portuguese version)
Spain (Spanish version)
South Korea (Korean version)
Brazil (Brazilian Portuguese version)
A systematic review concluded that while the LANSS shows good specificity across studies, its sensitivity varies more widely in different populations.
Self-Report Version (S-LANSS)
In 2005, Bennett et al. developed a self-report version called the S-LANSS, which does not require clinical examination. This version has also been validated in several countries.
References
Bennett, M. (2001). The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs. Pain, 92(1-2), 147-157.
Mathieson, S., Maher, C. G., Terwee, C. B., Folly de Campos, T., & Lin, C. W. (2015). Neuropathic pain screening questionnaires have limited measurement properties. A systematic review. Journal of Clinical Epidemiology, 68(8), 957-966.
Spanos, K., Lachanas, V. A., Chan, P., Bargiota, A., & Giannoukas, A. D. (2015). Validation of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) questionnaire and its correlation with visual analog pain scales in Greek population. Journal of Diabetes and its Complications, 29(8), 1142-1145.
Barbosa, M., Bennett, M. I., Verissimo, R., & Carvalho, D. (2014). Cross-cultural psychometric assessment of the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale in the Portuguese population. Pain Practice, 14(7), 620-624.
The DN4
The Douleur Neuropathique en 4 Questions (DN4) questionnaire was developed as a screening tool for neuropathic pain. Here are the key details about its development, validation, and international use:
Development
The DN4 was originally developed in France by a group of experts to address the difficulties in diagnosing neuropathic pain. It consists of 10 items - 7 related to pain quality based on patient interview, and 3 based on clinical examination.
Initial Validation
The original French validation study included patients with neuropathic and non-neuropathic pain. Pain classification was based on medical history, physical examination, and diagnostic tests by two independent physicians. The DN4 demonstrated a sensitivity of 83% and specificity of 90% in identifying neuropathic pain.
International Validation
The DN4 has been translated and validated in numerous countries and languages:
Arabic - Showed excellent diagnostic accuracy with 88.3% sensitivity and 74.5% specificity
Spanish - Demonstrated validity for differential diagnosis of pain syndromes
Dutch - Validated in a large consecutive chronic pain population
Thai, Portuguese, Turkish, Swedish, Italian, Persian, Greek, Korean, Hindi, Japanese, and Taiwanese versions have also been validated
Across various language versions, sensitivity ranged from 70% to 97% and specificity from 67% to 84%.
Key Findings
The 7-item version (interview only) generally shows lower sensitivity and specificity compared to the full 10-item version
It demonstrates moderate accuracy in detecting neuropathic pain components in mixed pain conditions
Test-retest reliability is high in both short-term and long-term assessments
The DN4 has proven to be a reliable and valid screening tool for neuropathic pain across multiple languages and clinical settings. However, comprehensive clinical examination remains essential for definitive diagnosis.
References
Bouhassira, D., Attal, N., Alchaar, H., Boureau, F., Brochet, B., Bruxelle, J., ... & Vicaut, E. (2005). Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain, 114(1-2), 29-36.
Timmerman, H., Steegers, M. A., Huygen, F. J., Goeman, J. J., van Dasselaar, N. T., Schenkels, M. J., ... & Vissers, K. C. (2017). Investigating the validity of the DN4 in a consecutive population of patients with chronic pain. PloS one, 12(11), e0187961.
Unal-Cevik, I., Sarioglu-Ay, S., & Evcik, D. (2010). A comparison of the DN4 and LANSS questionnaires in the assessment of neuropathic pain: validity and reliability of the Turkish version of DN4. The Journal of Pain, 11(11), 1129-1135.
The ODI
The Oswestry Disability Index (ODI) is a widely used patient-reported outcome measure for assessing functional disability in individuals with low back pain. Here are key details about its development, validation, and international use:
Development
The ODI was first published by Jeremy Fairbank and colleagues in 1980 in the journal Physiotherapy. It was developed to quantify disability for low back pain and assess quality of life. The questionnaire contains 10 sections covering different aspects of daily living affected by back pain, including pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex life, social life, and traveling.
Validation
The ODI has undergone extensive validation studies over the past 40+ years:
Construct validity has been demonstrated through correlations with other low back pain measures.
Internal consistency is rated as acceptable, with Cronbach's alpha values typically above 0.7.
Test-retest reliability has been shown to be high, with intraclass correlation coefficients often above 0.8.
Responsiveness to clinical change has been established in numerous studies.
International Validation
The ODI has been translated and validated in over 40 languages worldwide. Some examples of countries where it has been validated include:
France, Germany, Italy, Spain, Japan, China, Brazil, Turkey, Iran
Each translated version typically undergoes a rigorous cross-cultural adaptation and validation process to ensure its psychometric properties are maintained.
References
Fairbank, J. C., Couper, J., Davies, J. B., & O'Brien, J. P. (1980). The Oswestry low back pain disability questionnaire. Physiotherapy, 66(8), 271-273.
Vianin, M. (2008). Psychometric properties and clinical usefulness of the Oswestry Disability Index. Journal of Chiropractic Medicine, 7(4), 161-163.
Fairbank, J. C., & Pynsent, P. B. (2000). The Oswestry disability index. Spine, 25(22), 2940-2953.
Denis, I., & Fortin, L. (2012). Development of a French-Canadian version of the Oswestry Disability Index: cross-cultural adaptation and validation. Spine, 37(7), E439-E444.