ORIGINAL ARTICLE

The Pain Self-Efficacy Questionnaire: Cross-

Cultural Adaptation into Italian and Assessment
of Its Measurement Properties

Alessandro Chiarotto, MSc*,†; Carla Vanti, MSc‡; Raymond W. Ostelo, PhD*,§;

Silvano Ferrari, PT¶; Giuseppe Tedesco, PT†; Barbara Rocca, MSc**; Paolo
Pillastrini, MSc‡; Marco Monticone, MD, PhD**
*Department of Health Sciences, Faculty of Earth and Life Sciences, EMGO+ Institute for
Health and Care Research, VU University, Amsterdam, The Netherlands; †Department of
Evidence Based Physiotherapy, A.I.FI. Piemonte Valle d’ Aosta, Turin; ‡Department of
Biomedical and Neurological Sciences, University of Bologna, Bologna, Italy; §Department of
Epidemiology and Biostatistics, EMGO+ Institute for Health and Care Research, VU University
Medical Center, Amsterdam, The Netherlands; ¶Department of Biomedical Sciences, University
of Padova, Padova; **Operative Unit of Physical Medicine and Rehabilitation, Scientific
Institute of Lissone, Salvatore Maugeri Foundation, Lissone (MB), Italy

& Abstract: The Pain Self-Efficacy Questionnaire (PSEQ) is a
patient self-reported measurement instrument that evaluates
pain self-efficacy beliefs in patients with chronic pain. The
measurement properties of the PSEQ have been tested in its
original and translated versions, showing satisfactory results
for validity and reliability. The aims of this study were 2 fold as
follows: (1) to translate the PSEQ into Italian through a
process of cross-cultural adaptation, (2) to test the measure-
ment properties of the Italian PSEQ (PSEQ-I). The cross-
cultural adaptation was completed in 5 months without
Address correspondence and reprint requests to: Alessandro Chiarotto,
MSc, Department of Health Sciences, Faculty of Earth and Life Sciences,
EMGO+ Institute for Health and Care Research, Vrije Universiteit Amster-
dam, de Boelelaan 1085, Room T-525, 1081 HV, Amsterdam, The Nether-
lands. E-mail: a.chiarotto@vu.nl.
Disclosures: No funding sources were provided for this study. All
authors declare that they do not have any conflict of interest regarding
the content of this article.
Submitted: March 28, 2014; Revised July 1, 2014;
Revision accepted: August 20, 2014
DOI. 10.1111/papr.12242
omitting any item of the original PSEQ. Measurement prop-
erties were tested in 165 patients with chronic low back pain
(CLBP) (65% women, mean age 49.9 years). Factor analysis
confirmed the one-factor structure of the questionnaire.
Internal consistency (Cronbach’s a = 0.94) and test–retest
reliability (ICCagreement = 0.82) of the PSEQ-I showed good
results. The smallest detectable change was equal to 15.69
scale points. The PSEQ-I displayed a high construct validity by
meeting more than 75% of a priori hypotheses on correla-
tions with measurement instruments assessing pain intensity,
disability, anxiety, depression, pain catastrophizing, fear of
movement, and coping strategies. Additionally, the PSEQ-I
differentiated patients taking pain medication or not. The
results of this study suggest that the PSEQ-I can be used as a
valid and reliable tool in Italian patients with CLBP. &
Key Words: Pain Self-Efficacy Questionnaire, cross-cultural
adaptation, measurement properties, chronic low back pain,
Italy
INTRODUCTION

© 2014 World Institute of Pain, 1530-7085/14/$15.00

Low back pain (LBP) is a musculoskeletal disorder that
Pain Practice, Volume 15, Issue 8, 2015 738–747 represents the first cause of years lived with disability all

around the globe.1 Direct and indirect costs associated
with LBP are extremely high and they represent a
relevant burden to the society.2 A considerable amount
of patients experiencing an episode of LBP develop
chronic symptoms that can last a considerable amount
of time.3 Patients who suffer from chronic low back pain
(CLBP) usually display small reductions in pain and
disability over a 1-year period but without complete
resolution of symptoms.4
Several psychological factors can be present in
patients with CLBP, and they can play a key role in
the recovery from chronic symptoms.5,6 A prospective
cohort study investigating which psychological factors
were predictive of poor outcomes 6 months after initial
consultation identified 4 of them as significant predic-
tors.7 Two of these 4 psychological factors (ie, poor
perceptions of personal control and low confidence in
the ability to perform normal activities despite the pain)
fitted perfectly within the framework of the self-efficacy
model.7 Another observational study showed that pain
self-efficacy is a strong predictor of low levels of pain
intensity and disability in patients with CLBP.8 In the
same patients’ population, pain self-efficacy was also
shown to be a mediator in the relationship between pain
and disability.9
Self-efficacy is a personal belief about how success-
fully one can cope with difficult situations.10 When pain
represents the “difficult situation”, self-efficacy refers to
the degree of confidence a patient has in performing
regular activities despite the pain.11 The presence of low
levels of pain self-efficacy has been shown to be
associated with high levels of disability in different
samples of patients experiencing musculoskeletal
pain.12–14 Pain self-efficacy is usually measured by
means of self-reported questionnaires.
Miles et al.15 conducted a systematic review to
identify all questionnaires that evaluate pain self-effi-
cacy. Among those identified, only 2 questionnaires
asked specifically to the patients to take pain into
account when responding: the Pain Self-Efficacy Ques-
tionnaire (PSEQ)16 and the Self-Efficacy Scale (SES)17.
Between these 2 questionnaires, the PSEQ displayed
more satisfactory measurement properties with ade-
quate internal consistency, good content, and construct
validity.15
The original English version of the PSEQ was
developed in a sample of CLBP patients and subse-
quently tested in larger sample of heterogeneous chronic
pain patients.16 In both samples, the scale showed to
have a one-factor structure accounting for approxi-
Italian Pain Self-Efficacy Questionnaire  739
mately 60% of the total variance in scores.16 The
unidimensionality of the scale was also recently
confirmed by means of Rasch analysis in a large sample
of LBP patients.18 The original PSEQ has shown to have
high internal consistency16,18 and matched expected
hypotheses of correlations with number of medications
used, pain interference, psychological functioning, and
coping strategies and beliefs.16 Additionally, the results
showed evidence regarding the discriminative validity as
the PSEQ clearly distinguished between patients who
were taking medications with those who were not.16
The PSEQ has been translated and tested for its
measurement properties in other languages, such as
Chinese,19 Persian,20 Brazilian Portuguese,21 European
Portuguese,22 and Dutch.23 However, an Italian version
of this questionnaire is not available. This fact might
limit the opportunities of Italian health professionals
who wish to use if for clinical or research purposes.
Therefore, the aims of this study were (1) to translate the
PSEQ into Italian through a complete process of cross-
cultural adaptation and (2) to test its measurement
properties in an Italian sample of patients with CLBP.
METHODS
This clinimetrical study was approved by the Institu-
tional Review Board of Salvatore Maugeri Foundation’s
Scientific Institute of Lissone (Italy). All patients gave
their written consent before entering in the study, and all
procedures were conducted according to the Declaration
of Helsinki.
Patients
Patients were recruited in a rehabilitation hospital and 4
physical therapy services affiliated. These services were
chosen to represent different social and cultural contexts
in different Italian regions (ie, Piemonte, Lombardia,
and Emilia-Romagna). The recruitment phase was
conducted between March 2012 and July 2013. Inclu-
sion criteria were as follows: age between 18 and
70 years old, LBP with or without leg pain, LBP lasting
for at least 3 months, ability to read and speak fluently
in Italian. Patients were excluded if they presented
specific causes for LBP (eg, disk herniation, lumbar
stenosis, fracture, infection, tumor), central neurological
signs, systemic illnesses (eg, rheumatoid arthritis), severe
psychiatric disorders. Patients’ socio-demographic and
clinical characteristics were recorded together with all
measurement instruments. All data were checked for the
740  CHIAROTTO ET AL.
presence of missing responses or multiple answers.
Frequencies and descriptive statistics were used to
describe socio-demographic and clinical characteristics
of the patients.
The Pain Self-Efficacy Questionnaire
The PSEQ is used to measure pain self-efficacy and
consists of 10 items representing different daily activities
(eg, I can do most of the household chores) or general
aspects of life (eg, I can still accomplish most of my goals
in life).16 For each item, the patient has to rate how
confident he or she feels to perform these activities,
despite the presence of pain. Items are rated on a 7-point
Likert scale ranging from 0 (not at all confident) to
6 (completely confident). The total score of the ques-
tionnaire can range from 0 to 60, with higher scores
indicating higher pain self-efficacy.
Measurement Properties Assessment
The measurement properties analyzed in this study
followed definitions suggested by an international
multidisciplinary consensus-based procedure for
health-related self-reported measurement instruments.24
However, some properties such as criterion validity and
responsiveness could not be assessed, due to the lack of
an appropriate “gold standard” to measure pain self-
efficacy for the former, and due to the cross-sectional
nature of this study for the latter. In addition to
measurement properties, also acceptability and floor/
ceiling effects were assessed in this study.
Cross-cultural Validity. Cross-cultural validity covers
the performance of items of a translated and culturally
adapted questionnaire and assesses whether or not it is an
adequate reflection of the original version of the instru-
ment.24 The process of cross-cultural adaptation of this
study followed established guidelines for self-reported
measurement instruments.25 First, 3 Italian native speak-
ers with English proficiency translated independently the
PSEQ from English to Italian. Two of these translators
had a medical background and familiarity with the
construct measured by the scale, while the other trans-
lator had no familiarity and a background in Italian
literature. Translators aimed at keeping the language
colloquial and compatible with a reading age level of
14 years. The independent translations were discussed in
a meeting that was held to reach consensus on a prefinal
version of the questionnaire. Second, 2 bilingual English
native speakers performed independently a back trans-
lation of the Italian version. These 2 translators did not
have a medical background and were not aware of the
content of the original questionnaire. Third, original and
translated scales together with all forward and backward
translations were reviewed by a committee including
clinicians and clinimetrical experts. The committee
discussed differences in items and made decisions trying
to emphasize meaning over literal translation to achieve
conceptual equivalence. Fourth, the prefinal Italian
version of the PSEQ was administered to a group of
patients fulfilling the same inclusion criteria of the study.
These patients were asked to check the cultural relevance
of the items and to highlight those that were not clear or
had doubtful meaning. After this stage, the Italian
translation of the questionnaire was considered as ready
for testing its measurement properties.
Structural Validity. Structural validity is the degree to
which scores of an instrument adequately reflect the
dimensionality of the construct to be measured.24 In this
study, confirmatory factor analysis was used to test the
hypothesis that each item loads on the same factor as
already found by other studies.16,18–23 Model fit was
assessed using the following statistics: the comparative
fit index (CFI), the normed fit index (NFI), the root mean
square error of approximation (RMSEA), and the 90%
confidence interval (CI) of the RMSEA.26 Ratios of < 3
between the chi-square test and degrees of freedom, CFI
and NFI of 0.90 or more, and RMSEA values of 0.08 or
less were considered to indicate a good fit of the
model.26 Factor loadings for each item were also
calculated, and loadings smaller than 0.5 were consid-
ered for item reduction of the questionnaire.27 Confir-
matory factor analysis was performed with the software
LISREL version 9.1 (Scientific Software International,
Skokie, IL, USA).
Internal Consistency. Internal consistency refers to the
degree of interrelatedness among items, which indicates
the extent to which these items measure the same
construct.24 Cronbach’s a was the statistic calculated for
this property, and it was considered to be adequate
when between 0.70 and 0.95.28
Reliability. Reliability of self-reported questionnaires
concerns the extent to which scores for patients who
have not changed are the same for test and retest
measurements.24 To examine this property, patients
were administered the PSEQ-I in 2 independent

measurement sessions. The time interval between
assessments could be from 3 to 7 days, and, before
re-assessment, patients were asked whether they
reported any significant change in their clinical condi-
tion. The questionnaires were re-administered only if
patients did not report any important clinical change
between assessments. The intraclass correlation coeffi-
cient (ICCagreement) based on a 2-way random effects
model was used as a reliability statistic, and it was
evaluated as good when above 0.70.29
Measurement Error. Measurement error consists of the
systematic and random error of a patient’s score that is
not attributed to true changes in the construct to be
measured.24 In this study, the measurement error was
quantified using the Bland and Altman method. A
paired t-test provided the mean change (meanchange) in
score between the 2 time points and the standard
deviation of this change (SDchange). Then, the 95%
limits of agreement were calculated with the following
formula: meanchange  1.96 9 SDchange. Also the stan-
dard error of measurement (SEMagreement) was calcu-
lated to check how far apart the scores of the
2 measurements were.29 Finally, the smallest detectable
change (SDC) was calculated with the formula
1.96 9 √ 2 9 SEM, to estimate the smallest change
that can be considered as “real” change, beyond
measurement error.29
Construct Validity. Construct validity can be defined as
the degree to which the scores of a self-reported
instrument are consistent with hypotheses based on the
assumption that the instrument validly measures the
construct to be measured.24 For testing convergent
validity, a priori hypotheses were formulated regarding
the correlations between the PSEQ-I and other mea-
surement instruments reflecting other constructs.
To measure current pain intensity, an 11-point
Numeric Rating Scale (NRS) ranging from 0 (no pain
at all) to 10 (the worst imaginable pain) was used. This
instrument has shown to be valid and reliable to
measure pain intensity in chronic pain patients.30
The Roland Morris Disability Questionnaire
(RMDQ) is a 24-item self-reported questionnaire used
to measure the degree of back-related disability in
patients with LBP.31 Each item can be scored 1 if
applicable for the patient or 0 if not, and the total score
may vary from 0 (no disability) to 24 (maximum
disability). The cross-culturally validated Italian version
of the RMDQ that showed adequate internal consis-
Italian Pain Self-Efficacy Questionnaire  741
tency and good test–retest reliability was used in this
study.32
The Hospital Anxiety and Depression Scale (HADS)
consists of 14 items subdivided in 2 subscale scores
which assess anxiety (7 items) and depression levels (7
items). The total score for each subscale is calculated by
adding the scores of the individual item scales (0 to 3)
and ranges from 0 (low levels) to 21 (high).33 The Italian
version of the HADS was used in this study as it
demonstrated adequate internal consistency, good reli-
ability, and satisfactory construct validity with other
measures of emotional distress.34
The Pain Catastrophizing Scale (PCS) is a 13-item
questionnaire used to measure catastrophizing in
patients with musculoskeletal pain.35 Each item is
scored on a 5-point Likert scale ranging from 0 (never)
to 4 (always), providing a total score that can range from
0 to 52 and with higher scores indicating worst
catastrophizing. In this study, the cross-culturally
adapted Italian version of the PCS (PCS-I) was used as
it demonstrated adequate internal consistency and good
test–retest reliability; it also exhibited moderate corre-
lations with measures of pain intensity, disability, fear of
movement, and emotional distress in patients with
CLBP.36
The Tampa Scale of Kinesiophobia (TSK) evaluates
fear-avoidance behaviors related to pain.37 The cross-
culturally adapted Italian version of this questionnaire
(TSK-I) includes 13 items, and it showed adequate
internal consistency, good reliability, and moderate
correlations with measures of pain intensity and dis-
ability in patients with CLBP.38 Each item is a statement
which patients have to score on a 4-point Likert scale
ranging from 1 (strongly disagree) to 4 (strongly agree).
The total score can range from 13 to 52, with higher
scores indicating stronger fear-avoidance behaviors.
The 42-item version of the Chronic Pain Coping
Inventory (CPCI-42) is a self-reported questionnaire,
which asks the patient to rate the frequency of use of
behavioral and cognitive coping strategies during the
previous week.39 The 8-subscale structure of this scale
was confirmed in the cross-culturally validated Italian
version of the CPCI-42 that was used in this study.40
Each subscale provides a score from 0 to 7 with higher
scores indicating greater use of coping strategies. The
Italian CPCI-42 showed also adequate internal consis-
tency and good reliability in patients with musculoskel-
etal chronic pain.40
The PSEQ-I was hypothesized to have (1) a negative
high correlation (> 0.60) with the RMDQ; (2) a
742  CHIAROTTO ET AL.

negative moderate correlation (between 0.30 and lumbar spinal stenosis, 1 experienced LBP due to
0.60) with the NRS for pain intensity, with the trauma, 6 experienced LBP for < than 3 months, 6
depression and anxiety subscales of the HADS, with displayed clear signs of neurological deficits, 4 displayed
the PCS-I, with the TSK-I, and with the maladaptive severe cognitive or psychological impairment. Three
subscales (ie, guarding, resting, asking for assistance) of patients (1.5%) did not give consent to participate in the
the CPCI-42; (3) a weak correlation (between 0.30 and study. The remaining 165 patients with CLBP satisfied
0.30) with the adaptive subscales of the CPCI-42 (ie, the inclusion criteria. Socio-demographic and clinical
relaxation, task persistence, exercise, social support, characteristics of these patients are presented in Table 1.
coping self-statement). The normal distribution of the Almost 65% of them were women, the mean age was
data was checked through descriptive statistics and 49.94  12.43 years, and the median duration of LBP
visual inspection (ie, plotting histograms). Pearson was 24 months. All patients reported complete scores
correlation (r) was the statistic used to investigate
correlations when data were normally distributed for
both variables. When data were not normally distrib- Table 1. Socio-demographic and Clinical Characteristics
uted, the Spearman correlation (rs) was used. of the Patients Included in the Study
Discriminative validity was tested by hypothesizing a Gender n (%)
significant difference in PSEQ scores between patients Male 58 (35.2)
Female 107 (64.8)
taking or not pain medication. This supposed statistical Age, years
difference was explored with an independent t-test if Mean (SD) 49.9 (12.4)
Weight (self-reported), kilograms
data were normally distributed. If data were not Mean (SD) 69.28 (12.89)
normally distributed, the nonparametric Mann–Whit- Height (self-reported), meters
Mean (SD) 1.68 (0.09)
ney U-test was used. Construct validity was considered Pain duration, months
high when 75% of the formulated hypotheses were in Median (IQR) 24.0 (7.0; 96.0)
agreement with the results, moderate if 50% to 75% Civil state, n (%)
Married 106 (64.2)
were in agreement, and low when <50% were in Not married 56 (33.9)
agreement.29 Missing 3 (1.8)
Educational level, n (%)
Primary school 2 (1.2)
Acceptability. The time needed to complete the PSEQ-I Secondary school 38 (23.0)
High school 67 (40.6)
was recorded, and patients were asked about any University 58 (35.2)
problems they encountered while fulfilling the question- Work status, n (%)
Unemployed due to pain 2 (1.2)
naire. Student 4 (2.4)
Employee 113 (68.5)
Floor and Ceiling Effects. Floor and ceiling effects were Self-employee 24 (14.5)
Housewife 1 (0.6)
assessed and were considered present when more than Retired 21 (12.7)
15% of the sample reported the lowest or highest Smoking status, n (%)
Smoker 128 (77.6)
possible score for the PSEQ-I.29 Nonsmoker 34 (20.6)
Missing 3 (1.8)
Pain localization, n (%)
Statistical Analysis. All statistical analyses for internal Low back 109 (66.1)
consistency, reliability, measurement error, and con- Low back and leg 20 (12.1)
Low back and neck 18 (10.9)
struct validity were performed using the software SPSS Low back and thorax 8 (4.8)
version 20 (IBM, Armonk, NY, USA). Low back, leg, and neck 3 (1.8)
Low back, leg, and thorax 1 (0.6)
Low back, neck, and thorax 6 (3.6)
Use of pain medications, n (%)
RESULTS Yes 76 (46.1)
No 89 (53.9)
Number of comorbidities, n (%)
Patients
0 82 (49.7)
1 49 (29.7)
A total of 192 patients with LBP were screened against 2 24 (14.5)
eligibility criteria. Twenty-four of these patients 3 7 (4.2)
4 2 (1.2)
(12.5%) were excluded for different reasons: 5 under- 5 1 (0.6)
went low back surgery, 2 were clearly diagnosed with
 Italian Pain Self-Efficacy Questionnaire  743

Table 2. Descriptive Statistics of Measurement Table 3. Results of Confirmatory Factor Analysis Testing
Instruments Administered to the 165 Patients with the Structural Validity of the Pain Self-Efficacy
Chronic Low Back Pain of this Study Questionnaire in Italian Patients with Chronic Low Back
Pain
Outcomes Mean (SD)
Model v2/df CFI NFI RMSEA 90% CI RMSEA
Pain self-efficacy, PSEQ-I 36.12 (12.90)
Disability, RMDQ 8.92 (4.84) 1 Factor 3.398 0.971 0.959 0.121 0.097 to 0.145
Current pain intensity, NRS 4.58 (2.05) 1 Factor with 1.721 0.984 0.963 0.066 0.003 to 0.097
Psychological functioning, HADS error covariances*
Depression 6.85 (4.09)
Anxiety 4.92 (3.58) *The model included specified error covariances between the following items: 2-1, 5-2,
Pain catastrophizing, PCS-I 17.79 (10.69) 8-1, 8-4, 9-2, 9-8.
v2/df, ratio between the chi-square test and degrees of freedom; CFI, comparative fit
Fear of movement, TSK-I 29.85 (8.09) index; NFI, normed fit index; RMSEA, root mean square error of approximation; 90% CI,
Coping strategies, CPCI-42 90% confidence interval.
Guarding 2.10 (1.64)
Resting 2.39 (1.81)
Asking assistance 1.89 (1.73) After pilot-testing, the prefinal version of the question-
Relaxation 1.65 (1.40)
Task persistence 3.91 (1.72) naire was named as PSEQ-I. The whole process of cross-
Exercise/Stretch 2.49 (2.02) cultural adaptation lasted 5 months, from September
Seeking social support 1.75 (1.71)
Coping self-statements 4.06 (2.48)
2011 to February 2012.

PSEQ-I, Pain Self-Efficacy Questionnaire-I; RMDQ, Roland Morris Disability

Questionnaire; NRS, Numeric Rating Scale; HADS, Hospital Anxiety and Depression
Scale; PCS-I, Pain Catastrophizing Scale-I; TSK-I, Tampa Scale of Kinesiophobia-I; CPCI-
42, Chronic Pain Coping Inventory-42.
for all measurement instruments, and they were all
included in the analyses for measurement properties.
The PSEQ-I displayed a mean score of 36.12  12.90
points, the RMDQ of 8.92  4.84, and the NRS for
current pain intensity of 4.58  2.05 (Table 2).
Descriptive statistics for all other measurement instru-
ments are reported in Table 2.
Measurement Properties Assessment
Cross-cultural Validity. During the forward and back-
ward translation process, none of the original items were
omitted. The forward translations of several items were
broadly discussed in the meeting to reach consensus on
the prefinal version of the Italian PSEQ. A major point of
discussion was the translation of “confident” that
literally translated in Italian can have several meanings.
The chosen term for translation was correctly inter-
preted by the back translators who backward translated
it into “confident”. The committee reviewed and
approved the prefinal version of the questionnaire that
underwent pilot-testing. Twenty patients with CLBP
composed the sample for pilot-testing. Eleven of these
patients were women (55%), their mean age was
45.63  13.77 years, and their median pain duration
was 18 months. Their mean scores on self-reported
questionnaires were as follows: 40.37  13.45 on the
PSEQ, 9.00  4.28 on the RMDQ, and 4.37  1.46 on
the NRS. None of these patients reported difficulties in
completing and understating all the items of the PSEQ.
Structural Validity. Table 3 shows the results of
confirmatory factor analysis conducted to test the
one-factor structure of the PSEQ-I. The RMSEA value
obtained for the first model did not meet the criteria for
a good fit (Table 3). The model was adjusted on the
basis of modification indices that suggested to add error
covariances between error terms for the following item
pairs: 2-1, 5-2, 8-1, 8-4, 9-2, 9-8. The adjusted model
met all the criteria for a good fit (Table 3). Factor
loadings of the items ranged from 0.63 (item 7) to 0.90
(item 9) (Table 4).
Internal Consistency. Cronbach’s a for the whole
questionnaire was 0.94. Cronbach’s a if an item was
deleted ranged from 0.93 to 0.94. Item-total correla-
tions are presented in Table 4, and they ranged from
0.43 (item 7) to 0.81 (item 9).
Reliability. All patients did not report significant
changes in their clinical status between the 2 assess-
ments, and they were all re-administered the question-
naire. The mean score on the PSEQ-I for the second
assessment was 38.13  13.40. The ICCagreement was
equal to 0.82 (95% CI: 0.75 to 0.87).
Measurement Error. The 95% limits of agreement were
from 17.25 to 13.22, the SEMagreement was 5.66, and
the SDC was equal to 15.69 points on the PSEQ-I.
Construct Validity. The correlations between the
PSEQ-I and other measurement instruments are pre-
sented in Table 5. In the same table, it can be seen which
a priori hypotheses for correlations were met. The mean
744  CHIAROTTO ET AL.

Table 4. Descriptive Statistics, Factor Loadings, and Table 5. Hypothesized and Estimated Correlations
Item-total Correlations of the Items of the Pain Self- Between the Pain Self-Efficacy Questionnaire-I and Other
Efficacy Questionnaire-I in Italian Patients with Chronic Measurement Instruments in Italian Patients with
Low Back Pain Chronic Low Back Pain

Factor Item-Total Hypothesis

Item Description Mean (SD) Loading Correlation Hypothesized Estimated Acceptance
Outcomes Correlations Correlations (Yes or No)
1 I can enjoy things 3.47 (1.49) 0.78 0.75
2 I can do most of the 3.61 (1.52) 0.76 0.77 Disability, RMDQ 1.0, 0.6 0.659 Yes
household chores Current pain intensity, 1.0, 0.6 0.399 Yes
3 I can socialize with 4.33 (1.64) 0.81 0.79 NRS
my friends or family Psychological functioning,
members as often as HADS
I used to do Depression 0.6, 0.3 0.366 Yes
4 I can cope with my pain 3.82 (1.48) 0.68 0.65 Anxiety 0.6, 0.3 0.299 No
in most situations Pain catastrophizing, 0.6, 0.3 0.418 Yes
5 I can do some form 3.57 (1.54) 0.83 0.82 Pain PCS-I
of work Fear of movement, TSK-I 0.6, 0.3 0.484 Yes
6 I can still do many of the 3.22 (1.66) 0.80 0.65 Coping strategies, CPCI-42
things I enjoy doing Guarding 0.6, 0.3 0.414 Yes
7 I can cope with my pain 3.19 (1.73) 0.63 0.43 Resting 0.6, 0.3 0.169 No
without medication Asking assistance 0.6, 0.3 0.536 Yes
8 I can still accomplish most 3.72 (1.62) 0.86 0.77 Relaxation 0.3, 0.3 0.004 Yes
of my goals in life Task persistence 0.3, 0.3 0.240 Yes
9 I can live a normal lifestyle 3.82 (1.60) 0.90 0.81 Exercise/Stretch 0.3, 0.3 0.174 Yes
10 I can gradually become 3.56 (1.64) 0.84 0.69 Seeking social support 0.3, 0.3 0.278 Yes
more active Coping self-statements 0.3, 0.3 0.004 Yes

PSEQ score for the 89 patients (54% of the sample)
taking pain medication was 32.84  13.12, while for
the remaining sample not taking medication was
39.95  11.59. As hypothesized, this difference
was found to be statistically significant (P < 0.001).
Considering that more than 75% of the formulated
hypotheses were met (Table 5), the construct validity of
the PSEQ-I was considered as high.
Acceptability. The time needed to complete the PSEQ-I
was recorded with a subsample of 126 patients of the
total sample. These patients were 64.3% women, their
mean age was 50.79  12.68, and their median pain
duration was 24 months. Their mean scores on mea-
surement instruments were 35.47  12.32, 9.05  4.69,
and 4.61  2.04 for the PSEQ-I, the RMDQ, and the
NRS, respectively. The median time for completion was
3 minutes (IQR: 2; 5). None of the patients reported any
relevant difficulties while fulfilling the PSEQ-I.
Floor and Ceiling Effects. No significant floor or ceiling
effects were found. Two patients (1.2%) reported the
highest possible score (ie, 60/60), and no patients
reported the lowest possible score (ie, 0/60).
DISCUSSION
This study showed the successful cross-cultural adapta-
tion process of the PSEQ to the Italian language and
RMDQ, Roland Morris Disability Questionnaire; NRS, Numeric Rating Scale; HADS,
Hospital Anxiety and Depression Scale; PCS-I, Pain Catastrophizing Scale-I; TSK-I, Tampa
Scale of Kinesiophobia-I; CPCI-42, Chronic Pain Coping Inventory-42.
culture. In addition, the results of this study showed that
the PSEQ-I has a one-factor structure, adequate internal
consistency, good test–retest reliability, high construct
validity, appropriate acceptability, and no floor/ceiling
effects in Italian patients with CLBP.
The PSEQ had already been translated in Chinese,19
Persian,20 Brazilian Portuguese,21 European Portu-
guese,22 and Dutch.23 However, none of these studies
performed a complete cross-cultural adaptation includ-
ing multiple forward and backward translations, expert
committee revision, and pilot-testing of the question-
naire. These steps were all performed in this study as
they are necessary to bridge languages and cultural
differences (ie, translation alone is not sufficient).25
Therefore, this is the first work to conduct all relevant
steps for the cross-cultural adaptation of the PSEQ in a
language different from the original.
The mean score of the original PSEQ was
25.8  12.4 points in a sample of patients with
CLBP.16 These values differ from the ones obtained in
the present study (Table 2). Nevertheless, this differ-
ence can probably be attributed to the different care
settings of the 2 studies. In fact, Nicholas16 recruited
inpatients attending a pain management programme at
a hospital, while outpatients of physiotherapy services
were included in this study. Only 16.3% of the patients

in the original sample had a paid job, opposed to more
than 80% in this work (Table 1). Considering that
patients without a paid job were shown to have
significantly weaker pain self-efficacy beliefs,21,23 the
difference between these 2 studies can also be explained
by the work status of the patients. Di Pietro et al.18
analyzed 615 patients with LBP, but almost half of
them were experiencing subacute LBP. As a result, these
patients probably had higher pain self-efficacy as
demonstrated by their relatively higher total mean score
(ie, 43.1  12.4). The comparison with patients
included in other studies of the PSEQ is probably even
less meaningful, considering that they all recruited an
heterogeneous sample of patients with chronic
pain.16,19–23
This study confirmed the originally proposed one-
factor structure of the PSEQ,16 which was also con-
firmed by all subsequent factor analyses for original and
translated versions.18–23 At the same time, this study
was also in line with original and translated ver-
sions18,19,21–23 in describing item 7 (ie, I can cope with
my pain without medication) as the one with the
smallest factor loading (Table 4). However, the factor
loading found in this study is above the 0.5 threshold for
item reduction,27 and it is very similar to the values
found in the original (ie, 0.64), Chinese (0.69), Persian
(0.61), and Dutch (0.71) versions of the PSEQ.16,19,20,23
Therefore, this item remained included in the PSEQ-I,
also in view of the fact that it can provide relevant
clinical information to target inappropriate pain self-
efficacy beliefs in patients with CLBP.
The PSEQ-I showed adequate internal consistency
with a high Cronbach’s a (0.94) that was very similar to
the original (0.92), Chinese (0.93), Persian (0.92),
Brazilian Portuguese (0.90), and Dutch (0.92) ver-
sions.16,19–21,23 These high values are probably due to
the number of items of the PSEQ that tend to reduce the
error term in the denominator of the formula of
Cronbach’s a.27
This study provided the ICCagreement to evaluate
test–retest reliability of the PSEQ, and the result
(ICCagreemen = 0.82) can be compared with the
one obtained for the Dutch translation of the scale
(ICCagreement = 0.76).23 The higher score obtained with
the Italian version might be explained by the shorter
time interval adopted between assessments (ie, 3 to
7 days), compared to the flexible 4-week period of the
Dutch study.23 On one hand, it is possible that the time
interval adopted in this study was short enough for
patients to have a “memory effect” during the second
Italian Pain Self-Efficacy Questionnaire  745
assessment. On the other hand, it is also possible that the
time interval for the Dutch version was too long to keep
patients’ clinical status stable over time. Other studies
used ICCconsistency19,20 or Pearson correlation16 as
parameters of reliability. These parameters do not take
into account the potential systematic difference between
2 assessments,27 thus not allowing a direct comparison
with the ICC found in this study.
The 95% limits of agreement of this study ( 17.25 to
13.22) are quite similar to those of the Dutch PSEQ in
patients with musculoskeletal pain ( 15.56 to 13.03).23
These values indicated that 95% of the measurements
between the repeated assessments fell within the limits
of agreements. This consideration taken together with
the SDC (15.69 points in this study) provides important
information regarding the change that can be attribut-
able to measurement error. According to our results,
only a change bigger than 15.69 points on the PSEQ-I
can be considered as a “real” change on the construct
pain self-efficacy in patients with CLBP. However, these
results cannot be fully compared with other studies
because, to our knowledge, this is the first study to
provide the SDC for the PSEQ in patients with CLBP.
Future studies on the PSEQ in the same patients’
population should calculate the SDC to allow compar-
isons for this indicator.
Construct validity for the PSEQ-I was considered as
high as more than 75% of a priori hypotheses were
met.29 Higher pain self-efficacy levels were associated
with reduced disability, lower pain intensity, fewer
depressive and anxiety symptoms, less pain catastro-
phizing, and less fear of movement. Correlations with
disability, psychological functioning, pain catastro-
phizing, and fear of movement were in line with
previous studies finding similar results.16,19–23 How-
ever, the expected correlation between pain self-
efficacy and pain intensity was not always found to
be significant in preceding investigations.16,19,21 These
different results might be due to different clinical
characteristics of the patients and/or to differences of
the subdomain of pain intensity measured. For exam-
ple, in this study, “current pain intensity” on the NRS
was measured, whereas Nicholas measured “average
weekly pain” on a Pain Rating Chart.16 Differences in
the pain intensity subdomain and measurement instru-
ments should be standardized, to have more consistent
estimates of the association between the PSEQ and
pain intensity. The PSEQ-I displayed moderate corre-
lations with 2 maladaptive subscales (ie, “guarding”
and “asking for assistance”) of the CPCI-42 and a
746  CHIAROTTO ET AL.
low correlation with the third one (ie, “resting”).
These results are new and need to be compared with
future studies replicating correlations between these
measurement instruments. The discriminative validity
of the PSEQ in differentiating between patients taking
or not taking pain medication is not new finding,
given that the original version provided a similar
result.16
Four important considerations need to be taken into
account. First, the PSEQ-I was tested in a sample of
patients with CLBP; therefore, future studies should
evaluate whether its measurement properties are sim-
ilar in other pain populations before its use in those
populations. Second, the assessment of the measure-
ment properties of an instrument is a continuous
process; therefore, it is possible that the results of this
study will be strengthened or weakened by future
studies. Third, no studies have conducted a formal
assessment of the responsiveness of the PSEQ. This
assessment should include testing of a priori hypoth-
eses regarding correlations between change scores of
the PSEQ and change scores of other instruments
measuring other constructs.27,29 This lack in the
literature suggests caution in using the PSEQ-I as an
outcome measurement instrument to detect change
over time in the construct pain self-efficacy, even if
more studies have shown its ability to change follow-
ing treatment.16 Fourth, it would be relevant to
interpret the SDC found in this study against values
for the minimal important change (MIC) of the PSEQ.
However, no studies have calculated the MIC for this
questionnaire, and future studies should aim at filling
this gap in the literature.
In summary, the PSEQ was cross-culturally adapted
into Italian, and its measurement properties were tested
in a sample of Italian patients with CLBP. The PSEQ-I
demonstrated to have a one-factor structure, adequate
internal consistency, good test–retest reliability, and
high construct validity. In addition, this study was the
first to report a value for the SDC of the PSEQ that will
allow to distinguish between measurement error and
“real” clinical change. Given these results, the use of the
PSEQ-I can be recommended to Italian health profes-
sionals for clinical or research purposes with patients
experiencing CLBP.
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