An increased sensitivity to painful stimuli has been proposed to be related to the development of chronic pain. Therefore, assessment of individual pain sensitivity is useful in clinical practice. However, experimental pain testing may be uncomfortable for patients and requires specific equipment. The Pain Sensitivity Questionnaire (PSQ) has been developed to facilitate assessment of pain sensitivity. In this study, we aimed to translate and cross-culturally adapt the PSQ from its published German and English versions into the Dutch language and to assess validity of the PSQ in healthy volunteers. After translation and cross-cultural adaptation of the PSQ following international guidelines, we validated the PSQ in 394 healthy volunteers by comparing the PSQ-values with two different experimental pain tests: electrical pain tolerance (EPT) and pressure pain threshold (PPT). In addition, ratings of pain intensity during these tests were obtained on the numerical rating scale (NRS, 0–10). We found that the reliability of the PSQ based on internal consistency was good (Cronbach’s alpha 0.90). PSQ-scores, adjusted for age and sex, were statistically significant and weakly inversely correlated to EPT (PSQ-moderate: rho = −0.24,
Increased pain perception and pain sensitivity may be related to the development of chronic pain [
The PSQ is based on pain intensity rating of imagined painful daily life situations. The validity of the PSQ to measure perceived pain sensitivity has been shown by significant correlations with experimental pain intensity, both in healthy subjects and in patients with chronic pain [
According to these previous results, the PSQ might be a clinical useful instrument to screen patients’ pain sensitivity in the Netherlands. However, in order to use this tool in a Dutch population, the PSQ needs to undergo a translation into the Dutch language. The next step is to validate the new Dutch version of the PSQ in a population of healthy volunteers. Therefore, the aim of this study was to translate and cross-culturally adapt the PSQ from the published English and German versions into the Dutch language and to validate this instrument in a large group of healthy volunteers by comparing PSQ-scores with the results of experimental pain testing.
Permission was obtained from the initial developers (Ruscheweyh and coworkers) to develop and cross-culturally adapt a Dutch version of the PSQ and to validate this Dutch version of the PSQ against experimental pain testing. The validated German and English versions of the PSQ from the study of Ruscheweyh and coworkers [
Flow diagram of the translation and cross-cultural adaptation process.
Comparison of items in the original German PSQ with the published English PSQ for cross-cultural translation into the Dutch language.
Item number | Original German PSQ | Published English PSQ | Final Dutch PSQ | Reasons for change |
---|---|---|---|---|
[Instructions] | Sie sollen dann entscheiden, ob diese situation für sie schmerzhaft wäre, und wenn ja, wie schmerzhaft sie wäre | You should then decide if these situations would be painful for you, and if yes, how painful they would be | Het is de bedoeling dat | |
[ | Stellen sie sich vor, sie… | Imagine… | Stelt | Conforming to the German PSQ usage of formal language |
[ | Stellen sie sich vor, sie haben eine kleine Verletzung am Finger und bringen aus Versehen Zitronensaft in die Wunde | Imagine you have a minor cut on your finger and inadvertently get lemon juice in the wound | Stelt | Usage of diminutive for wound, which may feel as a very big wound in Dutch |
This observational study took place in 2016 during “Lowlands,” a 3-day festival with special attention for science, in Biddinghuizen, Netherlands. The study was conducted according to the Helsinki Declaration and was approved by the local research ethics committee on human research (Medical Review Ethics Committee Region Arnhem-Nijmegen) beforehand. It is registered as file number CMO: 2016–2784.
Participants were recruited by members of the research team when passing by the study facility. All participants were 18 years or older and could speak and read the Dutch language. All participants gave a written informed consent. Participants received no financial compensation for their cooperation. Exclusion criteria were as follows: use of pain killers in the last 12 hours, use of antidepressants, pain of the arm, neck or shoulder (uni- or bilaterally), cardiac disease, psychiatric or neurological disease, injury to the forearms or hands, Raynaud disease, pregnancy, blood alcohol content (BAC) of >220
The PSQ-total, PSQ-minor, and PSQ-moderate scores were evaluated for reliability by internal consistency using Cronbach’s alpha. Since twelve researchers performed electrical and pressure pain tests, we tested for operator effects, using one-way ANOVA, with Tukey’s post hoc testing with Bonferroni correction for multiple comparisons. Construct (convergent) validity was tested by evaluating the correlations between the PSQ and the experimental pain measures using Spearman’s rank correlation coefficient [
Data were analyzed using SPSS (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0, Armonk, NY: IBM Corp.) and
The enrolment process is shown in Figure
Flow diagram of the validation study. EPT: electrical pain tolerance measurement; PPT: pressure pain threshold measurement.
A small majority of the total cohort were female (54.8%), and the median age of the participants was 26 years (IQR 22–32; range 18–60 years). The distribution of age and sex of the study participants is shown in Table
Characteristics of the participants.
Total | Male | Female | |||||
---|---|---|---|---|---|---|---|
394 | 178 | (45.2%) | 216 | (54.8%) | |||
Age (year) | |||||||
18–28 | 90 | 50.6 | 137 | 63.4 | |||
29–38 | 48 | 27.0 | 55 | 25.5 | |||
39–48 | 22 | 12.4 | 10 | 4.6 | |||
49–58 | 8 | 4.5 | 5 | 2.3 | |||
59–68 | 1 | 0.6 | 1 | 0.5 | |||
Missing | 9 | 5.1 | 8 | 3.7 | |||
PSQ-minor (mean ± SD) | 2.8 | (±1.3) | |||||
PSQ-moderate (mean ± SD) | 5.3 | (±1.5) | |||||
PSQ-total (mean ± SD) | 4.1 | (±1.3) | |||||
EPT (mA, median, IQR) | 132 | 21.1 | (15.0 – 27.1) | ||||
NRS-EPT (median, IQR) | 7.0 | (6.0 – 8.0) | |||||
PPT (N, median, IQR) | 262 | 59.4 | (41.6 – 92.2) | ||||
NRS-PPT (median, IQR) | 3.0 | (2.0 – 5.0) |
SD: standard deviation; mA: milliampere;
Scores of the Dutch PSQ are reported in Table
Table
Construct validity was evaluated by examining the correlations between the PSQ-Dutch and the experimental pain measures using Spearman’s rank correlation coefficient. As shown in Table
Correlation between PSQ measures and QST measures (
EPT | EPT-NRS | PPT | PPT-NRS | ||||||
---|---|---|---|---|---|---|---|---|---|
Rho | Rho | Rho | Rho | ||||||
PSQ-minor | Crude | −0.120 | 0.171 | 0.217 | 0.012 | −0.074 | 0.235 | 0.349 | <0.001 |
Adjusted for age and sex | −0.170 | 0.059 | 0.207 | 0.021 | −0.106 | 0.097 | 0.324 | <0.001 | |
PSQ-moderate | Crude | −0.187 | 0.032 | 0.232 | 0.007 | −0.032 | 0.611 | 0.378 | <0.001 |
Adjusted for age and sex | −0.239 | 0.007 | 0.216 | 0.016 | −0.044 | 0.490 | 0.363 | <0.001 | |
PSQ-total | Crude | −0.165 | 0.059 | 0.243 | 0.005 | −0.052 | 0.397 | 0.395 | <0.001 |
Adjusted for age and sex | −0.216 | 0.016 | 0.233 | 0.009 | −0.078 | 0.222 | 0.374 | <0.001 |
EPT: electrical pain tolerance; NRS: numerical rating scale; PPT: pressure pain threshold;
Illustration of the correlations between total score of the Pain Sensitivity Questionnaire (PSQ) and results of experimental electrical pain testing. (a) Correlation between the total score of PSQ (PSQ-total) and the electrical pain tolerance (EPT). (b) Correlation between the total score of PSQ (PSQ-total) and the electrical pain tolerance numerical rating scale (EPT-NRS). Linear regression lines are displayed, and Spearman’s correlation coefficients (rho) as well as
Illustration of the correlations between total score of the Pain Sensitivity Questionnaire (PSQ) and results of experimental pressure pain testing. (a) Correlation between the total score of PSQ (PSQ-total) and the pressure pain threshold (PTT). (b) Correlation between the total score of PSQ (PSQ-total) and the pressure pain threshold numerical rating scale (PTT-NRS). Linear regression lines are displayed, and Spearman’s correlation coefficients (rho) as well as
The experience of pain may be influenced by confounding factors; therefore, partial correlation coefficients between PSQ-scores and experimental pain scores, adjusted for age and sex, were calculated (see Table
In this study, the PSQ was translated and cross-culturally adapted from both the English and German versions into the Dutch language. Furthermore, the instrument was validated in healthy volunteers. We found that the reliability via internal consistency of the PSQ-Dutch was high and that statistically significant correlations of weak to moderate magnitude were present between (1) the PSQ-moderate and PSQ-total and electrical pain tolerance and (2) all PSQ-scores and pain intensity ratings of both electrical and pressure pain stimuli. In contrast, there was no statistically significant correlation between PSQ and pressure pain thresholds. These relationships were maintained after controlling for age and sex.
We used the electrical pain tolerance as well as the pressure pain threshold [
The weak to moderate correlations we found in our study are comparable to those found in the original validation study as well as in the other language versions. Moreover, the reliability of the PPT and EPT was, based on other studies, acceptably high [
In our study, the score means of the PSQ were 4.1 ± 1.3 (PSQ-total), 2.8 ± 1.3 (PSQ-minor), and 5.3 ± 1.5 (PSQ-moderate) (see Table
Construct validity was demonstrated by the presence of correlations between the results of experimental pain tests and the PSQ. It has been previously reported that the PSQ shows little or no correlation with experimental pain thresholds but substantial correlations with experimental pain intensity ratings, and this has been interpreted within a framework of pain thresholds and pain intensity ratings representing two different dimensions of pain sensitivity [
The relation between experimental pain tolerance and the PSQ has been less explored. One previous study reported correlations around
The perceived pain intensity during the measurement of the electrical pain tolerance was in the study of Quan et al. (via VAS) 6.21 ± 2.02. We found for the same assessment modality a pain intensity of 7 (IQR 6–8), which seems comparable. The present results show that the PSQ-Dutch represents mainly the pain intensity rating dimension of pain sensitivity, as previously shown for the original German version [
The strengths of this study are firstly the cross-cultural adaptation performed via an internationally established guideline. Secondly, the pain sensitivity measurements were adequately standardized and trained in beforehand. Moreover, the study population consisted of a large sample of both men and women.
In this study, we noticed some weaknesses. In our study population, we noticed that most study participants had an age between 18 and 38 years, thus leading to a rather homogeneous study sample of healthy volunteers. We also found that the median PPT of one of our operators was statistically significantly different, due to some extreme values of PPT data. These extreme values however were valid and reliable data, and the removal of the data of this operator made no substantive difference in the results. Therefore, we chose not to remove them from our dataset to avoid the risk of selection bias and type 1 error [
Our study shows that the Dutch version of the PSQ was culturally appropriate for assessing self-reported pain sensitivity in Dutch adults. The instrument presented high internal consistency. Construct validity was similar to the original German version, with weak to moderate correlations between PSQ and experimental pain measures in healthy adult volunteers.
All data are available upon request to the corresponding author.
The authors report no conflicts of interest in this work.
The authors would like to thank all the participating volunteers in this study.
Dutch language version of the Pain Sensitivity Questionnaire (PSQ-Dutch).