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Neblett R, Sanabria-Mazo JP, Luciano JV, Mirčić M, Čolović P, Bojanić M, Jeremić-Knežević M, Aleksandrić T, Knežević A. Is the Central Sensitization Inventory (CSI) associated with quantitative sensory testing (QST)? A systematic review and meta-analysis. Neurosci Biobehav Rev 2024; 161:105612. [PMID: 38604015 DOI: 10.1016/j.neubiorev.2024.105612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 02/05/2024] [Accepted: 02/28/2024] [Indexed: 04/13/2024]
Abstract
Central sensitization (CS) involves an amplification of neural processing within the central nervous system that can result in widespread pain patterns and hypersensitivity to stimuli. The Central Sensitization Inventory (CSI) and various quantitative sensory testing (QST) methods purport to assess clinical markers of CS. The purpose of this systematic review and meta-analysis was to summarize and quantify the associations between total CSI scores and QST measures from previous studies. A systematic search identified 39 unique studies that were deemed eligible for the systematic review and 33 studies for meta-analyses (with 3314 subjects and 154 effect sizes), including five QST modalities: conditioned pain modulation, temporal summation, pressure pain threshold, heat pain threshold, and cold pain threshold. The meta-analysis yielded statistically significant CSI-QST correlations in total subject samples for all five QST modalities. The strongest associations were identified between CSI scores and pain threshold testing, especially pressure pain threshold, in which 51% of effects sizes, from 29 studies and 3071 subjects, were determined to be in a medium to large range.
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Affiliation(s)
- Randy Neblett
- PRIDE Research Foundation, Dallas, TX, United States.
| | - Juan P Sanabria-Mazo
- Teaching, Research, & Innovation Unit, Parc Sanitari Sant Joan de Déu, St. Boi de Llobregat, Spain; Centre for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Basic, Developmental, and Educational Psychology, Autonomous University of Barcelona, Cerdanyola del Vallès, Spain
| | - Juan V Luciano
- Teaching, Research, & Innovation Unit, Parc Sanitari Sant Joan de Déu, St. Boi de Llobregat, Spain; Centre for Biomedical Research in Epidemiology and Public Health (CIBERESP), Madrid, Spain; Department of Clinical and Health Psychology, Autonomous University of Barcelona, Cerdanyola del Vallès, Spain
| | - Milica Mirčić
- Faculty of Medicine University of Novi Sad, Novi Sad, Serbia
| | - Petar Čolović
- Department of Psychology, Faculty of Philosophy, University of Novi Sad, Novi Sad, Serbia
| | - Marija Bojanić
- Department of Psychology, Faculty of Philosophy, University of Novi Sad, Novi Sad, Serbia
| | | | - Tijana Aleksandrić
- Faculty of Medicine University of Novi Sad, Novi Sad, Serbia; Medical Rehabilitation Clinic, Clinical Centre of Vojvodina, Novi Sad, Serbia
| | - Aleksandar Knežević
- Faculty of Medicine University of Novi Sad, Novi Sad, Serbia; Medical Rehabilitation Clinic, Clinical Centre of Vojvodina, Novi Sad, Serbia
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Blajwajs L, Williams J, Timmons W, Sproule J. Hypermobility prevalence, measurements, and outcomes in childhood, adolescence, and emerging adulthood: a systematic review. Rheumatol Int 2023:10.1007/s00296-023-05338-x. [PMID: 37149553 DOI: 10.1007/s00296-023-05338-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 04/24/2023] [Indexed: 05/08/2023]
Abstract
General Joint Hypermobility (GJH) is a common condition found in 2-57% of the population. Of those with GJH, 10% suffer from accompanying physical and/or psychological symptoms. While the understanding of GJH in the general population is unfolding, its implication in a cohort of children, adolescents and young adults are not yet understood. This systematic review explored GJH's prevalence, tools to measure it, its physical and psychosocial symptoms, with a special interest in aesthetic sports. The CINHAL, MEDLINE, PsycINFO, SPORTDiscus and Scopus databases were searched for relevant studies. Inclusion criteria were (1) Age range of 5-24; (2) Participants had GJH; (3) A measurement for GJH; (4) Studies written in English language. Study screening for title, abstract and full text (when needed) and quality assessment were performed by two independent individuals. 107 studies were included in this review and were thematically grouped into six clusters expressing different foci: (1) GJH's Core Characteristics; (2) Orthopedic; (3) Physical Other; (4) Psychosocial; (5) Treatment and (6) Aesthetic Sports. The review revealed a growing interest in GJH in this cohort in the last decade, especially regarding non-musculoskeletal physical implications and psychosocial aspects. Prevalence varied between different ethnic groups and as a parameter of age, gender and measurement. The most widespread tool to measure GJH was the Beighton scale, with a cut-off varying between 4 and 7. Children show fewer, but similar GJH implication to those in the general population, however, more research on the topic is warranted, especially regarding psychosocial aspects and treatment.
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Affiliation(s)
- Liron Blajwajs
- Institute of Sport, Physical Education and Health Sciences, The University of Edinburgh, Edinburgh, UK.
| | - Joanne Williams
- Department of Clinical and Health Psychology, School of Health in Social Science, The University of Edinburgh, Edinburgh, UK
| | - Wendy Timmons
- Institute of Sport, Physical Education and Health Sciences, The University of Edinburgh, Edinburgh, UK
| | - John Sproule
- Institute of Sport, Physical Education and Health Sciences, The University of Edinburgh, Edinburgh, UK
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Clusters of facilitatory and inhibitory conditioned pain modulation responses in a large sample of children, adolescents, and young adults with chronic pain. Pain Rep 2022; 7:e1032. [PMID: 36213595 PMCID: PMC9534368 DOI: 10.1097/pr9.0000000000001032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 06/01/2022] [Accepted: 07/17/2022] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. Findings from the current study add to the literature by describing different clinical phenotypes of central pain mechanisms of youth with chronic pain. Introduction: When investigating the role of facilitatory and inhibitory pain mechanisms such as conditioned pain modulation (CPM) and temporal summation of pain (TSP), it is important to take both into consideration in a single experimental model to provide the most information on subgroups of patients. Therefore, the objective of this study was to identify subgroups in a large population of pediatric patients with chronic pain based on their facilitatory and inhibitory pain mechanisms and compare them with control subjects. Methods: Five hundred twenty-one female subjects and 147 male subjects between 8 and 21 years old underwent a CPM assessment using a 2-minute tonic noxious heat stimulation as the test stimulus and a 2-minute cold-pressor task (CPT) (12°C) as the conditioning stimulus. Results: The best partition of clusters of patients was 3 clusters accounting for 27.15% of the total variation in the data. Cluster 1 (n = 271) was best characterized by high pain intensity during the CPT, lack of TSP during the test stimuli, and efficient inhibitory CPM. Cluster 2 (n = 186) was best characterized by low pain intensity during the CPT, lack of TSP during the test stimuli, and efficient inhibitory CPM. Cluster 3 (n = 151) was best characterized by high pain intensity during the CPT, presence of TSP during the test stimuli, and inefficient inhibitory CPM. Discussion: A single thermal CPM experimental design can identify combinations of facilitatory and inhibitory pain modulation responses. Findings from the current study add to the literature by describing different clinical phenotypes of central pain mechanisms of youth with chronic pain.
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Arruda GT, Driusso P, Rodrigues JC, Godoy AG, Degani A, Danna-Dos-Santos A, Avila MA. Are menstrual symptoms associated with central sensitization inventory? A cross-sectional study. Eur J Pain 2022; 26:1759-1767. [PMID: 35761773 DOI: 10.1002/ejp.1999] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/13/2022] [Accepted: 06/26/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Dysmenorrhea is a prevalent pain condition that affects women of reproductive age, who are monthly exposed to this pain, usually until they reach the adult age, or even after that, which can predispose them to Central Sensitization. The present study aimed to observe the association between menstrual characteristics and central sensitivity symptoms in women. METHODS Cross-sectional study. Brazilian women (n=10,402) answered an online form comprised of questions regarding their gynecological history, the Numerical Rating Scale for pain and the Central Sensitization Inventory, part A. For the analysis, we separated women into two groups: Central Sensitivity Symptoms group (n=5,200) and No-Central Sensitivity Symptoms group (n=5,202). We performed a binary logistic regression with the backward insertion method for the variables with p<0.05 in the bivariate analysis between groups. The significance level was set at 5%. RESULTS Prevalence of dysmenorrhea was 67.3%, and 32.2% of women in the Central Sensitivity Symptoms group reported pain >8 during their menstrual period. The logistic regression showed that greater levels of menstrual pain (Odds Ratio 1.12), gynecological diseases (Odds Ratio 1.51), presence of dysmenorrhea since adolescence (Odds Ratio 1.20) and irregular menstrual cycles (Odds Ratio 1.47) increased the likelihood of women presenting with Central Sensitivity Symptoms (p<0.05 for all comparisons). CONCLUSIONS The present study shows that Central Sensitivity Symptoms are present in about 50% of women and are associated with menstrual characteristics such as dysmenorrhea-related pain intensity, cycle regularity, presence of dysmenorrhea since adolescence accompanied by gynecological diseases. SIGNIFICANCE Central sensitivity symptoms occur in 50% of women, and are more present in women with dysmenorrhea. They are associated with cycle regularity, presence of dysmenorrhea since adolescence, and gynecological diseases. LIMITATIONS Women that suffer from dysmenorrhea and of higher socioeconomic and educational levels may have been more propense to respond to the invitation; as such, the findings of the present study should be carefully interpreted.
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Affiliation(s)
- G T Arruda
- Physical Therapy Post-Graduate Program and Physical Therapy Department, UFSCar, Brazil.,Study Group on Chronic Pain (NEDoC), Laboratory of Research on Electrophysical Agents (LAREF), Physical Therapy Department, UFSCar, Brazil
| | - P Driusso
- Physical Therapy Post-Graduate Program and Physical Therapy Department, UFSCar, Brazil.,Laboratory of Research on Women's Health (LAMU), Physical Therapy Department, UFSCar, Brazil
| | - J C Rodrigues
- Physical Therapy Post-Graduate Program and Physical Therapy Department, UFSCar, Brazil.,Laboratory of Research on Women's Health (LAMU), Physical Therapy Department, UFSCar, Brazil
| | - A G Godoy
- Physical Therapy Post-Graduate Program and Physical Therapy Department, UFSCar, Brazil.,Study Group on Chronic Pain (NEDoC), Laboratory of Research on Electrophysical Agents (LAREF), Physical Therapy Department, UFSCar, Brazil
| | - A Degani
- Laboratory for Advancements in Rehabilitation Science, Department of Physical Therapy at Western Michigan University, Kalamazoo, MI, USA
| | - A Danna-Dos-Santos
- Laboratory for Advancements in Rehabilitation Science, Department of Physical Therapy at Western Michigan University, Kalamazoo, MI, USA
| | - M A Avila
- Physical Therapy Post-Graduate Program and Physical Therapy Department, UFSCar, Brazil.,Study Group on Chronic Pain (NEDoC), Laboratory of Research on Electrophysical Agents (LAREF), Physical Therapy Department, UFSCar, Brazil
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Ocay DD, Larche CL, Betinjane N, Jolicoeur A, Beaulieu MJ, Saran N, Ouellet JA, Ingelmo PM, Ferland CE. Phenotyping Chronic Musculoskeletal Pain in Male and Female Adolescents: Psychosocial Profiles, Somatosensory Profiles and Pain Modulatory Profiles. J Pain Res 2022; 15:591-612. [PMID: 35250304 PMCID: PMC8892739 DOI: 10.2147/jpr.s352607] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 01/26/2022] [Indexed: 12/17/2022] Open
Abstract
Purpose A major limitation in treatment outcomes for chronic pain is the heterogeneity of the population. Therefore, a personalized approach to the assessment and treatment of children and adolescents with chronic pain conditions is needed. The objective of the study was to subgroup pediatric patients with chronic MSK pain that will be phenotypically different from each other based on their psychosocial profile, somatosensory function, and pain modulation. Patients and Methods This observational cohort study recruited 302 adolescents (10–18 years) with chronic musculoskeletal pain and 80 age-matched controls. After validated self-report questionnaires on psychosocial factors were completed, quantitative sensory tests (QST) and conditioned pain modulation (CPM) were performed. Results Three psychosocial subgroups were identified: adaptive pain (n=125), high pain dysfunctional (n=115), high somatic symptoms (n=62). Based on QST, four somatosensory profiles were observed: normal QST (n=155), thermal hyperalgesia (n=98), mechanical hyperalgesia (n=34) and sensory loss (n=15). Based on CPM and temporal summation of pain (TSP), four distinct groups were formed, dysfunctional central processing group (n=27) had suboptimal CPM and present TSP, dysfunctional inhibition group (n=136) had suboptimal CPM and absent TSP, facilitation group (n=18) had optimal CPM and present TSP, and functional central processing (n=112) had optimal CPM and absent TSP. A significant association between the psychosocial and somatosensory profiles. However, no association was observed between the psychosocial or somatosensory profiles and pain modulatory profiles. Conclusion Our results provide evidence that adolescents with chronic musculoskeletal pain are a heterogenous population comprising subgroups that may reflect distinct mechanisms and may benefit from different treatment approaches. The combination of screening self-reported questionnaires, QST, and CPM facilitate subgrouping of adolescents with chronic MSK pain in the clinical context and may ultimately contribute to personalized therapy.
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Affiliation(s)
- Don Daniel Ocay
- Department of Experimental Surgery, McGill University, Montreal, QC, Canada
- Department of Clinical Research, Shriners Hospitals for Children Canada, Montreal, QC, Canada
| | - Cynthia L Larche
- Department of Clinical Research, Shriners Hospitals for Children Canada, Montreal, QC, Canada
| | - Natalie Betinjane
- Department of Clinical Research, Shriners Hospitals for Children Canada, Montreal, QC, Canada
| | - Alexandre Jolicoeur
- Department of Clinical Research, Shriners Hospitals for Children Canada, Montreal, QC, Canada
| | - Marie Josee Beaulieu
- Department of Clinical Research, Shriners Hospitals for Children Canada, Montreal, QC, Canada
| | - Neil Saran
- Department of Pediatric Orthopedics, McGill University, Montreal, QC, Canada
| | - Jean A Ouellet
- Department of Pediatric Orthopedics, McGill University, Montreal, QC, Canada
| | - Pablo M Ingelmo
- Edwards Family Interdisciplinary Center for Complex Pain, Montreal Children’s Hospital, Montreal, QC, Canada
- Department of Anesthesia, McGill University, Montreal, QC, Canada
- Research Institute-McGill University Health Centre, Montreal, QC, Canada
- Alan Edwards Research Center for Pain, McGill University, Montreal, QC, Canada
| | - Catherine E Ferland
- Department of Experimental Surgery, McGill University, Montreal, QC, Canada
- Department of Clinical Research, Shriners Hospitals for Children Canada, Montreal, QC, Canada
- Department of Anesthesia, McGill University, Montreal, QC, Canada
- Research Institute-McGill University Health Centre, Montreal, QC, Canada
- Alan Edwards Research Center for Pain, McGill University, Montreal, QC, Canada
- Correspondence: Catherine E Ferland, Shriners Hospitals for Children-Canada, 1003, Decarie Blvd, Montreal, H4A 0A9, Canada, Tel +1 514 842-4464, extension 7177,Fax +1 514 842-8664, Email
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Lam CY, Palsson OS, Whitehead WE, Sperber AD, Tornblom H, Simren M, Aziz I. Rome IV Functional Gastrointestinal Disorders and Health Impairment in Subjects With Hypermobility Spectrum Disorders or Hypermobile Ehlers-Danlos Syndrome. Clin Gastroenterol Hepatol 2021; 19:277-287.e3. [PMID: 32109633 DOI: 10.1016/j.cgh.2020.02.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/14/2020] [Accepted: 02/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Individuals with hypermobility spectrum disorder or hypermobile Ehlers-Danlos Syndrome (HSD/hEDS) are increasingly encountered by gastroenterologists and pose complex clinical challenges. Uncontrolled studies have found functional gastrointestinal disorders (FGIDs) to be common in patients with HSD/hEDS. Some patients have somatic symptoms (medically unexplained symptoms) that might affect FGIDs. We performed a case-control study to determine the prevalence of and factors associated with Rome IV FGIDs in subjects with HSD/hEDS compared with age- and sex- matched population-based controls. METHODS An online general health survey was completed by 603 individuals with HSD/hEDS in October 2018 (cases) and 603 matched individuals from the population of the United Kingdom (controls) in 2015. The mean participant age was 39 yrs, and 96% were women. The survey included questions about Rome IV FGIDs, non-GI and non-musculoskeletal somatic symptoms (maximum number, 10), quality of life, medical history and healthcare use. The prevalence of FGIDs was compared between cases and controls, with subsequent logistic regression models - adjusting for the number of somatic symptoms - used to determine the associations for FGIDs in HSD/hEDS compared with controls. RESULTS Nearly all subjects (98%) with HSD/hEDS fulfilled symptom-based criteria for 1 or more Rome IV FGIDs, compared with 47% of controls (P < .0001). The gastrointestinal regions most commonly affected by FGIDs in individuals with HSD/hEDS and control subjects were the bowel (90% vs 40% of controls), gastroduodenal (70% vs 13% of controls), esophageal (56% vs 6% of controls), and anorectal (53% vs 9% of controls); P < .0001. A higher proportion of subjects with HSD/hEDS had FGIDs in 2 or more regions (84% vs 15% of controls; P < .0001). Subjects with HSD/hEDS also reported a significantly higher number of non-GI and non-musculoskeletal somatic symptoms (7.1 vs 3.3 in controls), lower quality of life, and greater healthcare use, including abdominal surgeries and medication use (for example, 84% used analgesics compared with 29% of controls). Almost 40% of subjects with HSD/hEDS reported a diagnosis of chronic fatigue syndrome and/or fibromyalgia. Following adjustments for somatic symptoms, the association for FGIDs in subjects with HSD/hEDS was reduced by as much as 4-fold and in some instances was eliminated. CONCLUSIONS In a large case-control study of persons with HSD/hEDS, almost all of the cases met criteria for Rome IV FGIDs, incurred considerable health impairment, and had high healthcare use. Patients with HSD/hEDS frequently have somatic symptoms that should be treated to reduce the high burden of gastrointestinal illness in this population.
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Affiliation(s)
- Ching Y Lam
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom
| | - Olafur S Palsson
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina
| | - William E Whitehead
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina
| | - Ami D Sperber
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Hans Tornblom
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simren
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina; Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Imran Aziz
- Academic Department of Gastroenterology, Sheffield Teaching Hospitals, Sheffield, United Kingdom; Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.
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Esin O, Esin R, Gorobets E, Khairullin I, Makaricheva E, Gamirova R, Shamsutdinova R. Psychometric validation of the Russian version of the Central Sensitization Inventory in adolescents (14-17 years old). Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:72-76. [DOI: 10.17116/jnevro202112111272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Andias R, Silva AG. Cross-Cultural Adaptation and Psychometric Properties of the European Portuguese Version of the Central Sensitization Inventory in Adolescents With Musculoskeletal Chronic Pain. Pain Pract 2020; 20:480-490. [PMID: 32022985 DOI: 10.1111/papr.12875] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/17/2020] [Accepted: 01/22/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Central sensitization (CS) is an important feature in musculoskeletal chronic pain, and associated symptoms can be assessed using the Central Sensitization Inventory (CSI). OBJECTIVES This study aimed to translate and cross-culturally adapt the CSI to the European Portuguese language and to assess its validity and reliability in adolescents with musculoskeletal chronic pain. METHODS The European Portuguese version of the CSI was established following the translation and testing processes recommended by international guidelines. Then, this version of the CSI was completed by 1,730 adolescents, who also completed the Nordic Musculoskeletal Questionnaire; the Pain Catastrophizing Scale; the Depression, Anxiety and Stress Scale; the Tampa Scale of Kinesiophobia; and the Basic Scale on Insomnia Complaints and Quality of Sleep. Test-retest reliability and measurement error, internal consistency, hypothesis testing, and factor analysis were assessed for the translated version of the CSI. RESULTS Cronbach's alpha was 0.91, the intraclass correlation coefficient was 0.94 (95% confidence interval: 0.90, 0.96), and the standard error of measurement and smallest detectable change were 4.15 and 11.50, respectively. Fair correlations were found between CSI and fear of movement (Spearman's correlation [rs ] = 0.46), sleep (rs = 0.46), and catastrophizing (rs = 0.49). Moderate to good correlations were found between CSI and depression (rs = 0.60), anxiety (rs = 0.59), and stress (rs = 0.65). CONCLUSION The European Portuguese version of the CSI was considered easy to understand and showed very good internal consistency, excellent test-retest reliability, and excellent construct validity in a community sample of adolescents with musculoskeletal chronic pain.
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Affiliation(s)
- Rosa Andias
- School of Health Sciences, University of Aveiro, Aveiro, Portugal.,Center for Health Technology and Services Research (CINTESIS), Porto, Portugal
| | - Anabela G Silva
- School of Health Sciences, University of Aveiro, Aveiro, Portugal.,Center for Health Technology and Services Research (CINTESIS.UA), University of Aveiro, Aveiro, Portugal
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Christian BJ. Translational Research - Interventions for Promoting Health in Children. J Pediatr Nurs 2018; 42:118-121. [PMID: 30104056 DOI: 10.1016/j.pedn.2018.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Becky J Christian
- School of Nursing, The University of Louisville, Louisville, KY, USA.
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