Italian validation of the credibility/expectancy questionnaire in spinal pain: a useful tool for clinicians and physiotherapist (CEQ-I)

Abstract

Background:

The “credibility” and “expectation” regarding the treatment are important factors in the rehabilitation management of patients with spinal pain (SP).

Objectives:

The aim of this study was to translate, culturally adapt, and validate an Italian version of the credibility/expectancy questionnaire (CEQ-I) by Devilly and Borkovec (CEQ) for its application in SP in rehabilitative care.

Design:

Cross-sectional observational study.

Methods:

Ninety-nine patients (N = 99; mean age of 56.9 years ± 16.3 SD) with acute or chronic SP were recruited from September 2023 to September 2024. To evaluate construct validity, exploratory factor analysis (EFA) was conducted using a matrix of polychoric correlations along with promax rotation. The internal consistency and stability of the scale were evaluated using Cronbach’s alpha coefficient and test-retest analysis through the intraclass correlation coefficient (ICC). Pearson’s analysis between CEQ and other scales (Numeric Rating Scale, NRS; Roland and Morris-Disability Questionnaire, RMDQ; Oswestry Disability Index, ODI; Neuropathic Pain Symptom Inventory, NPSI) was employed to assess external validity.

Results:

Ninety-nine subjects were recruited. Test-retest reliability between two consecutive administrations of the CEQ showed an ICC of 0.90 (p < 0.001). The Kaiser-Meyer-Olkin (KMO) statistic was 0.81, indicating suitability for factor analysis. EFA revealed two factors—credibility and expectancy—accounting for 56.6% of the variance. Cronbach’s alpha indicated high internal consistency (0.85). External validation using Pearson’s correlation found no significant relationships between the CEQ subscale scores and NRS, RMDQ, ODI, and NPSI scales.

Conclusion:

The CEQ-I is a valid Italian translation of CEQ that demonstrates acceptable psychometric properties in SP in a rehabilitative setting. However, we recommend further analysis of the construct definition of the CEQ-I.

Plain language summary

A practical tool for assessing spinal pain: the Italian validation of the credibility questionnaire (CEQ-I)

In rehabilitative medicine, clinical scales and tests are indispensable tools for objectively and reliably measuring specific aspects concerning patients (e.g., strength, tone, pain, etc.). For their application in a population with a different language from that of origin, they must undergo formal approval (validation) through studies that meet international reference criteria. Our study aims to “validate” an important English scale in the clinical management of spinal pain, to facilitate clinical practice and research in the field. To do this, we asked 99 patients who visited the physiotherapy outpatient clinics at the research sites to respond to questions translated into Italian from the original English scale (CEQ scale by Devilly & Borkovec), which assesses the credibility and expectations of the patient regarding the rehabilitation treatment they are about to undergo. The study was conducted by applying statistical analysis to the data, which highlighted a strong correspondence between the questions asked and the expectations and feelings of the patients towards the prescribed therapies, as well as alignment with the original test. Therefore, we concluded that our translation is valid, providing a new tool that is easy to use and precise, to assist the Italian rehabilitation community in carrying out its work.

Keywords

credibility expectation outcome measure psychotherapy rehabilitation routine practice validation

Introduction

Spinal pain (SP), whether chronic or acute, commonly referred to as low back pain (LBP) or neck pain, is one of the most prevalent forms of chronic musculoskeletal pain. No individual therapy has consistent benefit, therefore multimodal treatment approach to chronic musculoskeletal pain is recommended. Multidisciplinary rehabilitation may be effective for short- and at least intermediate-term improvement in pain and function for SP and patients should be encouraged to engage in a variety of therapies aligned with their preferences and motivation.¹ Recommendations for rehabilitation highlight the possible advantages of education, exercise, manual therapy, and cognitive/behavioral approaches² in SP: the patient’s expectancy and credibility with respect to the treatment must always be considered to achieve the goal-setting of the individual rehabilitation plan. The biopsychosocial model in the multidisciplinary pain management program³ offers patients the chance to gain control over their pain issues, enabling them to achieve a quality of life that aligns with their expectations. Some studies underline how greater self-motivation and intentions and previous adherence to physical therapies could help improve the trust that the patient places in the treatment itself with a positive impact on the result.^4,5 These assumptions reflect an evolution of the healthcare model, which is coming oriented on the exercise of patient-oriented models with respect to approaches disease centered. The self-perceptions and related changes in motivation in physical therapy need to be monitored in rehabilitation to assist therapists in determining the patient’s readiness for specific outcomes of therapy (e.g., reduction of pain) and to underline positive issues that may hinder therapy progress.⁶ The patient’s trust and outlook regarding rehabilitation have recently been acknowledged as crucial factors in alleviating pain and enhancing function.^7,8 The credibility/expectancy questionnaire^9,10 (CEQ) is one of the most used measures to assess the patient’s credibility and expectancy, quick and easy-to-administer, which has shown results not only in reducing depression, anxiety, and general symptoms but also in the increase of the therapeutic alliance in physiotherapy.^11,12 The CEQ seemed to be a content-valid assessment tool for chronic pain (CP) patients awaiting rehabilitative treatment; however, it was found lacking in content validity for those who had already received treatment.¹³ In literature,^14,15 it appears that lower credibility is linked to increased pain-related fear and reduced internal control over pain, while lower expectations correlate with heightened levels of pain-related fear and the absence of radiating pain. Once more, credibility showed a significant relationship with patient-specific symptoms and satisfaction. In terms of overall perceived effect, treatment expectancy was a predictor only in the active physical therapy group, whereas treatment credibility was a significant predictor exclusively in the combination therapy group. While the relationships identified were weak to moderate, Smeets et al.¹⁴ indicate that expectancy and credibility play a crucial role in the outcomes of various active interventions for chronic low back pain (CLBP), potentially aiding in the creation of more effective treatment options. The CEQ scale has been employed in various rehabilitation settings.^12,16,17 Haanstra et al.^12,16 have indicated that optimism, pessimism, hope, treatment credibility, and treatment expectancy can be identified as distinct factors in patients undergoing hip and total knee arthroplasty. Specifically, they propose that optimism and hope tend to be relatively stable traits. However, it is important to assess interventions designed to modify treatment expectancy, as this aspect may be changeable and should be considered separately from optimism and hope. In addition, Courel-Ibáñez et al.¹⁸ employed the CEQ in patients with fibromyalgia, noting that these patients anticipated a 22%–38% enhancement in their symptoms following a rehabilitation intervention. However, the actual improvements recorded ranged from only 5%–26%. Despite the evidence in the literature supporting the evaluation of patient credibility and expectations prior to physiotherapy treatment, especially in the treatment of LBP, there are currently no validated and optimized tools for measuring these aspects in the Italian population.

Aim

This study seeks to adapt and validate the CEQ by Devilly and Borkovec^9,10 for the Italian context, particularly within the routine practice of physiotherapy for SP.

Materials and methods

A cross-sectional study was conducted to adapt and validate the CEQ for the Italian population (CEQ-I). The study was carried out at the rehabilitation clinic of the Sapienza University of Rome—Umberto I Polyclinic, from September 2023 to September 2024. The ethical committee of the University of Chieti Pescara has given a positive evaluation of the research (protocol number 24007-DISPuTER) following an initial review by the departmental board of the Department of Oral, Medical and Biotechnological Sciences, and approval was secured from the creator of the original CEQ.

Inclusion and exclusion criteria

The inclusion criteria were acute or chronic SP; aged between 18 and 70 years; able to read and speak Italian fluently. The exclusion criteria included: the presence of central or peripheral neurological signs; systemic diseases; psychiatric/mental disorders; recent cerebrovascular accidents; recent myocardial infarction; chronic lung disease; and chronic kidney disease. The demographic and clinical characteristics of the enrolled subjects were documented. All eligible patients provided their written consent to participate in the study.

Sample size calculation

The sample size needed for validating the questionnaire was established using the n:p rule of thumb,¹⁹ which indicates the minimum suggested ratio of sample size (n) to the number of variables being examined (p). The questionnaire intended for validation comprises six items. As per Everitt,²⁰ to determine the necessary number of participants for the study, the ratio of subjects to items (n:p) should be a minimum of 10. Thus, to satisfy this requirement, 60 subjects were recruited (n:p, 60:6 = 10). Taking into account a 30% dropout rate, the total number of participants needed was at least 78.

The credibility expectancy questionnaire

It is a self-administered questionnaire consisting of six items divided into two subscales: (i) credibility and (ii) outcome expectation.^9,21 The subjects who have higher levels of credibility and expectation are more likely to engage in therapy, participate actively, and achieve better outcomes. The first section contains four questions, while the second section includes the remaining items. Overall, three questions (1, 3, 5) address credibility and investigate: the logic of the treatment, the patient’s trust in recommending it to a friend, and the effectiveness of the therapy itself. The last three items (2, 4, 6) focus on the patient’s expectations by assessing their beliefs about the therapy’s effectiveness on their symptoms, their anticipated success, and the expected level of symptom improvement. They distinguish between the patient’s subjective feelings about improvement and their perception of the therapy’s actual effectiveness. The initial version utilized a Likert scale ranging from 1 to 9, where a score of 1 indicated “not at all” and a score of 9 represented “very” or “very useful” for credibility-related questions. For expectation questions, a scale from 0% to 100% in 10% increments was employed. The midpoint was labeled as “fairly useful.” To streamline the questionnaire, we standardized the expectation questions to also use the 9-point Likert scale.

Outcome measures

Numeric Rating Scale

A one-dimensional scale is used to assess the intensity of a patient’s pain, represented numerically similar to the visual analog scale. This scale typically consists of a horizontal line, approximately 10 cm in length, with its ends marked by two verbal descriptions. The endpoints are 0, indicating “no pain,” and 10, signifying “the worst possible pain.” The scale is categorized as follows: 0 signifies no pain; values from 1 to 3 indicate mild pain; values from 4 to 6 reflect moderate pain; and values from 7 to 10 denote severe pain intensity.²²

Roland and Morris-Disability Questionnaire

The most commonly used assessment tool for measuring disability related to LBP in clinical research is the Roland and Morris-Disability Questionnaire (RMDQ). This scale comprises 24 questions that examine the patient’s ability or limitations in performing various activities. These activities encompass areas such as physical capabilities, psychological well-being, sleep quality, managing household tasks, eating, and the frequency of pain. The patient assigns a score of 0 to an activity if they do not find it limiting, and one point if they find it challenging due to back pain. The highest possible score is 24, indicating the maximum level of disability.^23,24

The Oswestry Disability Index

This self-evaluation questionnaire is organized into 10 distinct sections. One section focuses on assessing pain, while the other nine sections examine the various limitations a person with LBP may encounter during daily activities. Each section is scored on a scale from 0 to 5, where 5 indicates the highest level of disability. If all sections are answered, the maximum possible score is 50 points. If any section is left incomplete, the highest achievable score is adjusted to 45 points. The scores for each section are then totaled, multiplied by two, and expressed as a percentage, with a maximum of 100% indicating complete disability. For interpretation, the Oswestry Disability Index (ODI) is categorized into five levels: (1) 0%–20%, indicating minimal disability; (2) 21%–40%, suggesting moderate disability; (3) 41%–60%, indicating severe disability; (4) 61%–80%, representing a high level of disability similar to that of paraplegic individuals; (5) 81%–100%, signifying total disability comparable to that of bedridden patients.^25,26

Neuropathic Pain Symptom Inventory

Neuropathic Pain Symptom Inventory (NPSI) assesses the neuropathic components of lower back pain; it comprises 12 questions organized into four sections. Ten questions describe various symptoms, while two assess the duration of both spontaneous and paroxysmal pain. The first section (items 1, 2, 3) identifies the presence of spontaneous painful sensations (burning, squeezing, and compression) on an 11-point numerical scale (0 = “no sensation of,” 10 = “the worst sensation of”). Furthermore, the patient is inquired about the duration of spontaneous pain experienced within the past 24 h. The second section (items 5, 6) examines paroxysmal pain, investigating whether it is associated with sensations akin to electric shocks or stabbing, as well as the frequency of these episodes during the last 24 h. In the third part (items 8, 9, 10), the patient is questioned about pain triggered by touch, pressure, or exposure to cold. Finally, in items 11 and 12, details are gathered regarding paresthesia, dysesthesia, and tingling sensations. As the temporal inquiries concerning spontaneous and paroxysmal pain do not contribute to the overall score, the final score is determined solely by the results of the 10 rated questions.^27,28

Translation and cross-cultural adaptation

The protocols established by the American Association of Orthopedic Surgeons Outcomes Committee were adhered to in the procedures.²¹ Initially, the items extracted from the original CEQ were translated into Italian to preserve the original concepts while incorporating culturally and clinically appropriate expressions. The translation was carried out by an Italian translator who works as a high school English teacher, opting for a colloquial style suitable for readers aged 18 and older. Any discrepancies in the choice of words were addressed by discussing with a second Italian translator expert in the English language until an agreement was reached. All of the items were included. Next, an independent bilingual translator whose first language is English, and who has no medical background or knowledge of the concepts being investigated, performed a back-translation into English. The purpose of this process was to ensure that the Italian version conveyed the same content and meaning as the original CEQ version. Finally, a specialized committee consisting of six members, including clinicians, methodologists, and translators, evaluated the semantic, idiomatic, and conceptual dimensions of the items and responses, and collaboratively developed a final version that all members agreed upon. The scale was subsequently given to 10 patients experiencing SP to assess the interpretation of each item and the responses selected. The results were subjected to evaluation by the expert committee and no need for adjustments emerged except for some grammatical errors. Finally, the unanimously approved version was used for the validation study (the CEQ-I scale in Italian is attached).

Data collection procedure

Outpatients visiting the center during the study period were evaluated by two physiatrists, supervised by the principal investigator. Therefore, after carefully evaluating the inclusion and exclusion criteria, previously described, and explaining the purpose of the study to the enrolled and included patients, the signing of the informed consent was requested. Once the patients had given their approval to participate in this research, their demographic and clinical characteristics were recorded by a research assistant and participants completed all the questionnaires described in the dedicated paragraph.

Statistical analysis

Descriptive

A descriptive analysis was performed using means and standard deviations for quantitative variables, or medians along with the 25th and 75th percentiles (interquartile range) when normality assumptions were not met. Percentages were utilized for qualitative variables. The Shapiro-Wilk test was conducted to evaluate the normality of the data.

Validation

The validation analysis was carried out using the following method: (1) A test-retest comparison was performed by computing the intraclass correlation coefficient (ICC) for the scores obtained during the two assessments (T0 and after 15 days). We calculated the ICC for the two-way random-effects model. This time interval is generally used as it is short enough to ensure the stability of the trait to be measured and long enough not to repeat on the memory of the previous answer. This was done to assess the stability of the construct within a subset of the sample (n = 10). This number was chosen for the initial stability assessment because it was considered sufficient to generalize the result. The higher the coefficient, the greater the stability; (2) the Kaiser-Meyer-Olkin test (KMO) to determine the data adequacy for factor analysis, taking the value 0.70 as the threshold; (3) exploratory factor analysis (EFA) was conducted for items measured using a Likert scale, employing a polychoric correlation matrix. The number of dimensions to be extracted, corresponding to underlying factors, was established through Horn’s parallel analysis. Item loadings on the extracted factors were evaluated following a promax rotation, with a minimum loading of 0.40. Subsequently, scores for each dimension were calculated; (4) to assess the reliability of the questionnaire, Cronbach’s alpha was utilized to evaluate internal consistency, with a threshold set at 0.70; (5) further validation of the scores was conducted through specific analyses—including the Pearson correlation coefficient and/or the Spearman’s rank correlation coefficient—compared against relevant clinical variables and established gold standard scales that are validated for clinical use. Statistical significance was defined at the <0.05 level. All analyses were executed using STATA software version 18.0 (StataCorp, College Station, TX, USA).

Results

The questionnaire was translated into Italian through a forward-backward translation method, utilizing the expertise of three translators. The items were straightforward to translate. The evaluation of the pre-final version validated both the translation/back-translation process and the relevance of the items and their responses. Ninety-nine participants were enrolled in the study, with an average age of 56.9 years (standard deviation of ±16.3). The majority of the participants were female, comprising 64.6% of the group. In addition, the mean body mass index recorded was 25 (±4.2 SD). Access to the outpatient clinic was due to the presence of localized musculoskeletal pain in the spine (lumbar 61.2%, thoracic 17.3%, cervical 21.4%) mostly chronic (59.6%). To investigate the living conditions that may affect the overall well-being perception, the level of education (high school degree 40.4% and university degree 37.4%), participation in work activities (54.1%), and marital status (71.4%) were recorded. The presence of comorbidities was also investigated and found to be high in the sample population (71.7%), as well as adherence to physical activity (80%) mostly mild in a subpopulation of 75 individuals, mostly focused on walking and other types of activities (37.8%; Table 1). The CEQ-I test was administered simultaneously with other tests with the aim of also highlighting any correlation with the pain investigated through the most commonly used questionnaires (Numeric Rating Scale (NRS), RMDQ, ODI, and NPSI). The tests were administered at T0 and then at T1 after 15 days, and the results were subjected to statistical analysis.

Table 1.

Characteristics of the subjects n = 99.

Sociodemographic variables	Specifics	Results (N)	N%	Mean	SD+/−
Age (years)				56.9	16.3
Sex	M	35	35.4
	F	64	64.4
Weight (kg)				70.4	15.1
Height (cm)				125.4	72.8
BMI				25.0	4.2
Educational level	Elementary school	7	7.1
	Middle school	15	15.2
	High school	40	40.4
	Degree	37	37.4
Occupation	No employed	45	45.9
	Employed	53	54.1
Marital status	Married/cohabitant	70	71.4
	Others	28	28.6
Musculoskeletal pain	Acute	35	35.4
	Subacute	5	5.1
	Chronic	59	59.6
Pain site	Cervical	21	21.4
	Dorsal	17	17.3
	Lumbar	60	61.2
Hours of physical activity per week				1.7	2.6
Intensity of physical activity	Mild	60	80.0
	Moderate	13	17.3
	Intense	2	2.7
Type of physical activity	Cyclette	2	4.4
	Postural	4	8.9
	Walking	22	48.9
	Others	17	37.8

N% or mean ± SD are shown when appropriate. For some variables, the descriptive statistics were calculated only on the available information.

We also present the findings for the average values and variability (ds) of the primary clinical scales measuring pain and disability (Table 2).

Table 2.

Mean values and standard deviations of the scales used.

Scales at baseline	Mean ± SD
NRS	6.04 ± 1.68
RMDQ	9.84 ± 4.77
ODI	12.80 ± 7.01
NPSI	12.47 ± 9.52

NPSI, Neuropathic Pain Symptom Inventory; NRS, Numeric Rating Scale; ODI, Oswestry Disability Index; RMDQ, Roland and Morris-Disability Questionnaire.

The test-retest reliability of the CEQ-I questionnaire was evaluated in a subgroup of 10 participants, with the two assessments taking place 15 days apart. This evaluation utilized the ICC for analysis.²⁹ The ICC yielded a score of 0.90 (95% confidence interval: 0.64–0.97), with a significance level of p < 0.001, indicating a high level of reliability between the two assessments.

Study of validation and reliability of CEQ-I questionnaire

The KMO test, which evaluates the suitability of data for factor analysis, yielded a KMO value of 0.81, indicating good adequacy. An EFA employing a promax rotation revealed two underlying factors that together accounted for 56.6% of the overall variance (see Table 3 for details). In addition, the graphical representation of eigenvalues and the results from parallel analysis corroborated this finding (Figure 1).

Table 3.

Factor analysis (n = 99).

Factor	Eigenvalue	% Variance	% Cumulative
Factor 1	2.912	48.55	48.55
Factor 2	0.486	8.11	56.66

Figure 1.

Parallel analysis conducted on the six-item CEQ-I questionnaire.

The questionnaire factor structure for Italian CEQ-I consists of two subscales: credibility (factor 1—item 1, 3, and 5) and expectancy (factor 2—item 2, 4 and 6; Table 4).

Table 4.

Credibility and expectancy questionnaire factor structure for Italian CEQ-I (n = 99).

Items	Factor 1	Factor 2
1. At this point, how logical does the therapy offered to you seem?	0.777	–0.052
2. At this point, how successfully do you think this treatment will be in reducing your trauma symptoms?	0.306	0.579
3. How confident would you be in recommending this treatment to a friend who experiences similar problems?	0.743	0.034
4. By the end of the therapy period, how much improvement in your trauma symptoms do you think will occur?	–0.109	0.739
5. At this point, how much do you really feel that therapy will help you to reduce your trauma symptoms?	0.649	0.257
6. By the end of the therapy period, how much improvement in your trauma symptoms do you really feel will occur?	0.187	0.571

In bold, the items associated with credibility (factor 1) and expectancy (factor 2).

CEQ-I, Italian version of the credibility/expectancy questionnaire.

Furthermore, the CEQ-I questionnaire demonstrated strong internal consistency within our cohort, with a Cronbach’s alpha of 0.85 overall. Specifically, the credibility subscale had an alpha of 0.83, while the expectancy subscale returned a value of 0.77.

Validity of CEQ-I questionnaire

The external validation of the CEQ-I subscale scores was performed by conducting a Pearson correlation analysis to assess the relationship between credibility and expectancy, and the scores from the NRS, RMDQ, ODI, and NPSI scales (Table 5). We found no significant correlations between CEQ-I subscales and standardized scales.

Table 5.

Pearson’s correlation analysis between credibility and expectancy and NRS, RMDQ, ODI, and NPSI scales at baseline.

Scales	Credibility		Expectancy
NRS	r = 0.09	p = 0.378	r = −0.09	p = 0.931
RMDQ	r = −0.01	p = 0.921	r = −0.04	p = 0.630
ODI	r = 0.11	p = 0.260	r = 0.07	p = 0.434
NPSI	r = 0.17	p = 0.076	r = 0.04	p = 0.625

NPSI, Neuropathic Pain Symptom Inventory; NRS, Numeric Rating Scale; ODI, Oswestry Disability Index; RMDQ, Roland and Morris-Disability Questionnaire.

Discussion

The usefulness of the CEQ is highlighted not only through clinical studies incorporating it into research protocols in its original language but also by the efforts of two working groups that have recognized the necessity for cross-cultural adaptation and validation of this tool in French³⁰ and Portuguese.¹⁰ To enable Italian researchers to benefit from this valuable tool, this study outlines the Italian adaptation and validation of the CEQ for patients suffering from SP. The findings from the adaptation process demonstrate that it was successfully carried out in accordance with established international guidelines.²¹ The validation process of the CEQ is crucial for ensuring its reliability and relevance in assessing therapeutic expectations and perceived credibility related to treatment procedures. The findings of this study provide significant insights into the psychometric properties of the CEQ-I, confirming its robustness in a clinical setting. The observed ICC of 0.90 underscores the excellent test-retest reliability of the CEQ-I. With a high level of reliability indicated by a 95% confidence interval ranging from 0.64 to 0.97, the CEQ-I demonstrates consistent performance across time intervals, affirming its utility as a stable measurement tool. The significance level of p < 0.001 further solidifies these findings, suggesting that the CEQ-I can reliably measure constructs of credibility and expectancy over a 2-week period, in line with the original study and other similar research previously referenced.^9,30 This reliability is important for ensuring that the questionnaire consistently measures the same constructs over time.

The successful application of EFA yielded a two-factor structure, which aligns with the conceptual framework underlying the CEQ-I. The KMO value of 0.81 supports the data’s appropriateness for factor analysis, affirming that the sample size and variance are adequate for extracting meaningful factors. The identification of two underlying constructs—Credibility (Factor 1) and Expectancy (Factor 2), which together account for 56.6% of the variance—illustrates that the CEQ-I is methodologically sound in capturing these distinct aspects of therapeutic evaluation, as original and similar previous works demonstrated.^9,13,30

In terms of the factor loadings, items associated with Credibility (items 1, 3, and 5) and Expectancy (items 2, 4, and 6) show strong correlations with their respective factors, further validating the construct validity of the questionnaire. This bifactorial nature not only enhances the interpretative richness of the questionnaire but also suggests that interventions focusing on enhancing treatment credibility and patient expectancy could potentially optimize therapeutic outcomes.

Internal consistency, as indicated by a Cronbach’s alpha of 0.85, reveals strong coherence within the CEQ-I, affirming its reliability as a measure. The individual subscales also reflect satisfactory internal consistency, with alpha values of 0.83 for credibility and 0.77 for expectancy. These results imply that the items within each subscale measure their respective constructs effectively, contributing to the overall reliability of the instrument. This suggests that the questionnaire is measuring a coherent set of constructs.

However, when it comes to external validation, we did not find any significant correlations between the subscales of the CEQ-I and other standardized scales such as the NRS, RMDQ, ODI, and NPSI. This may suggest that the CEQ-I is measuring different aspects of pain perception and expectation than these other scales, or that these scales may assess different constructs altogether.

Also, the results demonstrate that our study has validated an Italian version of the CEQ scale (CEQ-I) an instrument already recognized in international literature as important in the therapeutic path of pain reduction and improvement of functionality, also useful in chronic forms.^13,14

Assessing the CEQ-I can significantly impact the effectiveness of treatments for CP, especially in cases of CLBP. This research is particularly pertinent given that there are currently no validated assessment tools available in Italy for evaluating these aspects in rehabilitation programs. Obtaining this tool and being able to apply it in CP is crucial to improve the research and clinical-rehabilitative approach to this issue in our country.

Future research could explore the relationship between the CEQ-I questionnaire and other measures of pain perception and expectation, to further evaluate its external validity. In addition, examining the sensitivity of the CEQ-I questionnaire to changes in pain perception and expectation over time could provide further evidence of its utility in clinical settings.

The CEQ is not the only scale that analyzes basic constructs and a person’s ability to rely on others. There are indeed other tests, such as the Expectation for Treatment Scale (ETS),³¹ the Pain Catastrophizing Scale (PCS),³² and the Treatment Expectation Questionnaire (TEX-Q).³³ Beyond the limitations of these others, such as their application or development in limited contexts or for specific aspects of the investigation, only the CEQ fully and reliably investigates both aspects of the patient.

Conclusion

In summary, our research demonstrates robust support for the CEQ-I questionnaire as an effective instrument for evaluating pain perception and expectations. The questionnaire exhibits excellent test-retest reliability, a sound factor structure, and strong internal consistency, highlighting its significance for both researchers and clinicians who are focused on exploring and quantifying these critical concepts. Future research should explore the interplay between CEQ-I scores and various clinical outcomes to further elucidate its potential role in enhancing patient care. The CEQ-I shows promise in identifying patient expectations and the perceived credibility of treatments, ultimately facilitating more personalized and effective therapeutic approaches. Furthermore, any responsiveness to gender and, possibly, to age should be further investigated, also taking into account the smallest detectable change through randomized controlled clinical studies.

Key points

The Italian version of the CEQ (CEQ-I) has demonstrated robust psychometric properties, especially in terms of test-retest reliability, internal consistency, validity, and its ability to detect change;

Factor analysis indicated that a two-factor model effectively captures both treatment expectancy and the credibility of the rationale;

It is advised that the CEQ-I be integrated into rehabilitation assessment and research practices in Italy.

Footnotes

Appendix

Acknowledgements

The authors thank Alessio Di Lanzo and Ludovica De Filippis for their help in sample recruitment; also, the authors thank Prof. Marco Monticone for his suggestions in preparing this article. The authors thank the study investigators and patients who participated in this study. All the mentioned individuals have authorized the authors to be included in the acknowledgments.

Declarations

ORCID iDs

Laura Belinda Rizzo

Letizia Pezzi

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