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Bottom line
The CSI appears to be the most reliable patient-reported tool for assessing central sensitization in chronic pain, but evidence for all instruments remains incomplete and more validation research is needed.
Moderate evidencePublished
Evidence hierarchy
Study participants
Adults with chronic pain conditions including fibromyalgia, chronic low back pain, neck pain, chronic widespread pain, and mixed/musculoskeletal pain
Study Summary
This systematic review and meta-analysis, conducted using COSMIN guidelines, identified and appraised the measurement quality of eight patient-reported outcome measures (PROMs) used to assess central sensitization (CS) in adults with chronic pain. Across 58 included studies, most instruments had limited evidence for their psychometric properties, often reflecting few publications and doubtful or inadequate study methodology rather than necessarily poor instruments. The Central Sensitization Inventory (CSI) received the highest overall ratings (sufficient on six of nine measurement properties, with moderate-to-high quality of evidence), followed by the Pain Sensitivity Questionnaire (PSQ) and Fibromyalgia Survey Questionnaire (FSQ). Pooled test-retest reliability was excellent for the CSI (ICC 0.93 overall chronic pain) and PSQ (ICC 0.86), though heterogeneity was high and no PROM had been evaluated across all nine measurement properties.
Key Findings
| Finding | Detail | Impact |
|---|---|---|
| The Central Sensitization Inventory (CSI) had the strongest measurement evidence of the eight instruments | CSI was the most frequently studied PROM (37 studies) and was rated 'sufficient' for content validity, structural validity, internal consistency, reliability, construct validity (83% of results aligned with hypotheses), and responsiveness, with high-quality evidence for most properties. | High |
| Pooled test-retest reliability of the CSI was excellent | Random-effects meta-analysis of 17 studies gave an ICC of 0.93 (95% CI 0.91-0.95) for overall chronic pain, 0.90 (95% CI 0.87-0.93) for chronic musculoskeletal pain, and 0.93 (95% CI 0.88-0.99) for chronic neck pain, though heterogeneity was substantial (I-squared 70.7-94.4%). | High |
| The Pain Sensitivity Questionnaire (PSQ) also showed excellent test-retest reliability | Pooled ICC for PSQ was 0.86 (95% CI 0.72-0.99, I-squared 87.4%) in chronic pain, but it was rated 'insufficient' for construct validity because 25% of study results did not align with hypotheses. | Medium |
| Most PROMs had limited psychometric evidence | Five of the eight instruments (NFF, GPQ, SHS, a Novel Self-report Questionnaire, and L-VISS/VDS) had measurement properties assessed in only a single study each, and no instrument had been evaluated across all nine COSMIN measurement properties. | High |
| Study methodological quality was frequently doubtful or inadequate | Common shortcomings included unclear reporting of the content-validation process, absence of factor analysis before computing internal consistency, failure to calculate the minimal important change (MIC) for measurement error, and unassessed cross-cultural validity despite 42 studies evaluating translated versions. | Medium |
CSI was the most frequently studied PROM (37 studies) and was rated 'sufficient' for content validity, structural validity, internal consistency, reliability, construct validity (83% of results aligned with hypotheses), and responsiveness, with high-quality evidence for most properties.
Random-effects meta-analysis of 17 studies gave an ICC of 0.93 (95% CI 0.91-0.95) for overall chronic pain, 0.90 (95% CI 0.87-0.93) for chronic musculoskeletal pain, and 0.93 (95% CI 0.88-0.99) for chronic neck pain, though heterogeneity was substantial (I-squared 70.7-94.4%).
Pooled ICC for PSQ was 0.86 (95% CI 0.72-0.99, I-squared 87.4%) in chronic pain, but it was rated 'insufficient' for construct validity because 25% of study results did not align with hypotheses.
Five of the eight instruments (NFF, GPQ, SHS, a Novel Self-report Questionnaire, and L-VISS/VDS) had measurement properties assessed in only a single study each, and no instrument had been evaluated across all nine COSMIN measurement properties.
Common shortcomings included unclear reporting of the content-validation process, absence of factor analysis before computing internal consistency, failure to calculate the minimal important change (MIC) for measurement error, and unassessed cross-cultural validity despite 42 studies evaluating translated versions.
Strengths
- Identified all available PROMs for central sensitization manifestations in chronic pain rather than a single instrument
- Used the most current COSMIN methodology for systematic appraisal of both study quality and instrument psychometric properties
- Pooled reliability quantitatively in a random-effects meta-analysis where data allowed
- Dual independent reviewers with expert adjudication of conflicts
- Protocol pre-registered (PROSPERO CRD42023460050) and reported per PRISMA-COSMIN
Limitations
- The COSMIN-based rating system can be subject to reviewer subjectivity, despite consensus procedures
- Only English-language studies were included, excluding three studies on the CSI and PSQ published in other languages (language bias)
- Findings are based only on adult populations and may not generalize to pediatric patients
- Substantial statistical heterogeneity in the pooled reliability estimates (I-squared up to 94.4%)
- Most instruments had measurement properties assessed in very few (often single) studies, and many included studies had doubtful or inadequate methodological quality
- Publication bias could not be formally assessed, as no accepted method exists for systematic reviews of PROM measurement properties
Key Takeaways for Patients
What This Means for You
- 01Central sensitization is a process where the nervous system becomes overly sensitive, so pain can persist even when there is no clear ongoing tissue damage.
- 02Questionnaires that ask about your own symptoms (patient-reported outcome measures) are a standard, accepted way to assess this kind of pain.
- 03Of the eight questionnaires reviewed, the Central Sensitization Inventory (CSI) had the strongest and most consistent evidence and produced very stable results when the same people retook it.
- 04No single questionnaire has been fully validated on every quality measure yet, so clinicians should choose the assessment tool carefully and more research is still needed.
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