Rev. Bras. Reumatol. vol.56 número5

w w w . r e u m a t o l o g i a . c o m . b r

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Original

article

The

European

Portuguese

adaptation

of

the

Fear

of

Pain

Questionnaire

Susana

Cardoso

,

Daniel

Esculpi

,

Ana

Rita

Carvalho

,

Diana

R.

Pereira

,

Sandra

Torres

_,

_Francisco

_Mercado

_,

_Fernando

_Barbosa

a_{LaboratóriodeNeuropsicofisiologia,FaculdadedePsicologiaedeCiênciasdaEducac¸ão,UniversidadedoPorto,Porto,Portugal} b_{CentrodePsicologia,FaculdadedePsicologiaedeCiênciasdaEducac¸ão,UniversidadedoPorto,Porto,Portugal}

c_{FaculdadedeCiênciasdaSaúde,UniversidadeReyJuanCarlos,Madrid,Spain}

d_{LaboratóriodeNeuropsicofisiologia–CIPsi,EscoladePsicologia,UniversidadedoMinho,Braga,Portugal}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received1June2015 Accepted13October2015 Availableonline16March2016

Keywords: Chronicpain Fear

Painassessment Anxiety

a

b

s

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t

InPortugal,itisestimatedthatchronicpainaffects36.7%ofthepopulation,constitutinga multifactorialphenomenonwithgreatimpactatindividual,family,community,andsocial levels.Inthefear-avoidancemodelofpain,oneofthemostconsistentconsensualinthe literature,thefeararisesasoneofthevariablesthatcancontributetothedevelopment andmaintenanceofthiscondition.Thus,instrumentsforevaluatingthefearofpain,as FearofPainQuestionnaire(FPQ-III_{),maybeusefulintheconceptualizationofthe} subjec-tiveexperienceofpain.Accordingly,thispaperaimstodescribetheadaptationofFPQ-III fortheEuropeanPortuguese.Atotalof1094participants(795women;meanage=25.16, SD=7.72)completedthewebbasedquestionnaire.Theresultspointedtoadifferent fac-torsolutionfoundinthefirststudyoftheoriginalscale(fivefactors:minorpain,severe pain,medicalpain,injectionpain,andafflictedpain),goodinternalconsistency(.75–.85) andgoodcorrelations(between.30and.59)betweensubscalesand(between.68and.85)for thetotalscoreandsubscales.Giventheneedtomeetthevariousdimensionsofsubjective experienceofpain,theFearofPainQuestionnaireisassumedasausefultool,in combina-tionwithother,maycontributetotheevaluationandinterventionproceduresprogressively morecomprehensiveandadjustedtothechallengesraisedwiththeissueofchronicpain.

©2016ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

∗ _{Correspondingauthor.}

E-mail:susanacardoso2004@yahoo.es(S.Cardoso).

http://dx.doi.org/10.1016/j.rbre.2016.02.012

2255-5021/©2016ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/

Fear

of

Pain

Questionnaire:

adaptac¸ão

para

o

português

europeu

Palavras-chave: Dorcrônica Medo

Avaliac¸ãodador Ansiedade

r

e

s

u

m

o

Em Portugal,estima-se quea dor crônica afete 36.7% da populac¸ão, constituindo um fenômenomultifatorialcomgrandeimpactoemnívelindividual,familiar,comunitárioe social.Nomodelode medo-evitamentodador,umdos maisconsensuaisnaliteratura, omedosurgecomoumadasvariáveisquepodemcontribuirparaodesenvolvimentoe a manutenc¸ãodessacondic¸ão.Assim,instrumentosdedicadosà avaliac¸ãodomedo da dor,comooFearofPainQuestionnaire(FPQ-III_{),podemserúteisnaconceitualizac¸ãoda} experiênciasubjetivadedor.Emconcordância,estetrabalhotemcomoobjetivodescrever aadaptac¸ãodoFPQ-III_{paraoportuguêseuropeu.Preencheramoquestionáriopela} inter-net1.094participantes(795mulheres;idademédia=25,16,DP=7,72).Osresultadosobtidos apontamparaumasoluc¸ãofatorialdiferentedaencontradanoprimeiroestudodaescala original(cincofatores:dorleve,intensa,médica,deinjec¸ãoeaflita),umaboaconsistência interna(entre.75e.85),boascorrelac¸õesentresubescalas(entre.30e.59)eentreessase apontuac¸ãototal(entre.68e.85).Peranteanecessidadedeatenderaváriasdimensõesda experiênciasubjetivadedor,oquestionáriodemedodadorassume-secomouma ferra-mentaútilque,emcombinac¸ãocomoutras,podecontribuirparaprocessosdeavaliac¸ãoe deintervenc¸ãoprogressivamentemaiscompreensivoseajustadosaosdesafioslevantados pelaproblemáticadedorcrônica.

©2016ElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCC BY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Speakingofchronicpainmeanstalkingaboutamultifactorial phenomenonwithasignificantimpact,eitheronanindividual basis(becausetherearechangesassociatedwith functional-ityinday-to-dayactivities,well-being,suffering,andmental

and physical health), and in terms of other dimensions

(such as family, community, and socioeconomic

environ-ment).Whileitisrecognizedthatchronicpainhasasignificant impactonseverallevels, beinginfluencedbymultiple vari-ables(biopsychosocialmodel),1_{itsdefinitionisnotcompletely} consensualandmayvarydependingonthe

socio-historical-cultural dynamics. However, one of the most widespread

definitionsistheoneproposedbytheInternational Associ-ationfortheStudyofPain(IASP),2_{whichdescribesthepain}

as an unpleasant subjective, sensory and emotional

expe-rience, related to current or potential tissue harm, or to a description that can be contextualized in terms of such damage.

Thiscomplexityintheconceptualizationofchronicpain isalsoreflectedintermsofexplanatorymodelsofthe

phe-nomenon. Oneof the mostinvestigatedapproaches isthe

cognitive-behavioralmodeloffear-avoidanceofpain,which wasfirstdevelopedinthecontextofchroniclowbackpain,3,4 butthathasalsobeenexploredinotherpainconditions,such asheadacheandfibromyalgia.5–7_{Accordingtothismodel,the}

development and maintenanceof chronic pain dependon

thesubject’sresponseinthefaceoftheexperienceofpain, thatcanbeofcopingoravoidance.3,4,8,9_{Inascenarioofpain} coping,theindividualtakesthenecessarystepstorestrict sit-uationsthatcouldhinderhis/herrecoveryprocess,andatthe sametimeseeksgraduallyresumehis/heractivities. There-fore,thepotentialfearofpainweakensovertime.Ontheother hand,inacaseofpainavoidance,thesubjectcatastrophizes

theexperienceofpain,whichmeansthatthereisanegative exacerbationofthisexperience,tothepointofthe develop-mentofapermanentfearofpainand/orofre-injury.4_Thisfear ischaracterizedbybehaviorsofescape/avoidanceofactivities thatareconsideredaspainful(functionalitychangesin every-dayactivities),byagreaterphysiologicalreactivity,bymood changes(e.g.,irritability,frustration,depression),andalsoby anincreasedhypervigilanceinthefaceofinternaland exter-nalinformationindicatingpain.10 _{Thus,thecatastrophizing} behaviorleadstothedevelopmentoffearofpain,leadingtoa fear-avoidancecyclethatself-perpetuatesandcontributesto themaintenanceofchronicpain.11

Consistent withthis model,several studies haveshown thatthefearofpainisarelevantvariableinunderstanding the subjectiveexperienceofpain,12_{and it isrelatedtothe} processofcatastrophizing,13_{ofhypervigilanceinthefaceof} somaticstimuli,14_{andofbeingdirectlyimplicatedin} explain-ingchangesfoundintermsoffunctionality.13,15–19

Methods

Participants

Thesamplingmethodwasofnon-probabilistictype,andthe questionnairewasinitiallycirculatedamongstudentsatthe UniversityofPorto(Portugal),whowerealsoaskedtodisclose thestudyintheirnetworkofcontacts.Thesampleconsisted of1094individuals,ofwhich795werewomen,recruitedfrom thePortuguesepopulationwithaccesstoacomputerandthe Internet,withameanageof25.16(SD=7.72)years.Itis note-worthythatallparticipantswhosemotherlanguagewasnot thePortuguese(n=40)wereexcludedfromthisstudy.

Materials

FPQ-III20_{isashortquestionnaireconsistingof30items,which} areansweredinaLikertscaleoffivepoints,rangingfrom1(not atall)to5(extreme).Eachitemseekstorepresenta poten-tiallypainfulsituation(e.g.,breakingyourleg,gettingapaper cutinyourfinger,havingabloodsampledrawnwitha hypo-dermicneedle),andthesesituationsarerelativelycommon andaccessibletothesubject’sexperience,evenifindirectly, bysharingexperienceswithothers.FPQ-III20_{includesthree} subscales:aminorpainsubscale,aseverepainsubscale,and amedicalpainsubscale.Thehigherthescoreobtained(range 30–150),thegreaterthepainoffearlevels.The psychomet-ricpropertiesreportedintheoriginalstudyareconsideredas satisfactory,withgoodinternalconsistency(˛=0.92fortotal scale;˛=0.88forseverepain;˛=0.87forminorpain;˛=0.92for medicalpain)andgoodtest–retestreliability(˛=0.74fortotal scale;˛=0.69forseverepain;˛=0.73forminorpain;˛=0.76 formedicalpain).20 _{Other studiesbasedonthis scaleor in} adaptedversionsalsoreportedsimilarresults.21–23

Procedures

Thetranslationandculturaladaptationofthequestionnaire

were carried out according to the internationally

recom-mendedmethodology.24–30 _{Thefollowingstepswere taken:} translation,pre-test on a sample ofthe target population,

and retroversion. Three psychology professionals did the

translation in parallel into the European Portugueseidiom usingtheoriginalversionofFPQ-III.20_{Thetranslationswere}

reviewed by a panel composed of these three psychology

professionalsand ofaclinical psychology expert.The

ver-sion that resulted from this meeting was administered to

three pilot participants, resorting to the spoken reflection

method.Thethreeparticipantshad amedium/higherlevel

ofeducation.For this purpose,aprotocol withopen-ended

questions was developed, in order to explore the

under-standingofthe instructions, thecontent oftheitems, and responsealternatives.Ingeneral,thisproceduresoughttotest whetherthequestionnairecontentswereaccessibleandclear tothetargetpopulation.Noneoftheparticipantsinthepilot studysuggestedanychange;thus,thefinalversionremained

identical to that that had been decided at the consensus

meeting.Finally,theretroversionofthefinalversionintothe

English idiom was done by a bilingual English-Portuguese

psychologist, and the result was compared withthe origi-nal version, toensure the preservation ofthe meaningof items.24–30

ThePortugueseversionwasincludedinGoogleDocs(2014, GoogleInc., California,USA)and administeredthrough the onlinequestionnaires’module.Theinformationnecessaryto obtainaninformedconsent(e.g.,thestudyexplanation, char-acteristics ofa voluntaryparticipation,confidentiality) was inserted,andalsosomeitemsdedicatedtothecollectionof

demographic data. Thelinkofthe questionnairewas then

made public to students of the University of Porto (Portu-gal)via e-mail;alsothedisseminationofthequestionnaire bytheircontactnetworkwasrequested.Inthecontextof fill-ingthequestionnaire,thefollowinginstructions(translated fromtheoriginal)weregiven,accordingtotheaforementioned process:“Thesentenceslistedbelowdescribepainful experi-ences.Pleasereadeachstatementandthinkabouthowmuch FEARdoyouhavewhenexperiencingthePAINassociatedwith eachphrase.IfyouhaveneverexperiencedthePAINdescribed inanyspecificphrase,pleaseanswerbasedonwhatyouwould expecttofeelifyouhadsuchanexperience.Pleasedrawa cir-clearoundascoreforeachsentenceinordertomarktheFEAR TOTHEPAINwithrespecttoeachoftheevents.”

Results

Table1presentstheresultsofdescriptivestatisticsofthe

Por-tugueseversionforeachitem.

Factoranalyses

A confirmatory factorial analysis to test the three-factor modelsuggestedbytheoriginalauthors oftheFearofPain Questionnaire-III20_{wascarriedout.Themodelwasevaluated} using the Comparative Fit Index (CFI),the Goodness ofFit Index(GFI),andtheRootMeanSquareErrorof Approxima-tion (RMSEA).Theadjustmentindexes(CFI=0.76,GFI=0.79, RMSEA=0.09)werenotsatisfatory31_{;thereforeanexploratory} factorialanalysiswascarriedout.

ThefactorialanalysesofFPQ-III20_{intheoriginalstudyused} varimax rotation. Thisisan orthogonalrotation, assuming thattheextractedfactorsareindependentofeachother(that is,theyhavenocorrelationwitheachother).32,33_Theanalysis resultedinfivefactorswitheigenvaluesgreaterthan1,also supportedbythescreeplotanalysis.

Thefivefactorsmodel(severepain, minorpain,medical pain,injectionpain,andafflictedpain)represented55.9%of totalvariance.Thefirstfactorexplained32.7%ofthevariance (eigenvalue=9.82),the secondfactorexplained8.45%ofthe variance (eigenvalue=2.54), the third explained 21.6% of the variance (eigenvalue=1.86), the fourthexplained 4.95% of the variance (eigenvalue=1.49), and the fifth explained 3.58%ofthevariance(eigenvalue=1.07).

Table1–DescriptivestatisticsoftheitemsoftheEuropeanPortugueseversionofFearofPainQuestionnaire(FPQ-III).

Items M SD Asymmetry Kurtosis

1.Beinginanautomobileaccident 3.74 0.918 −0.470 −0.138

2.Bitingyourtonguewhileeating 2.15 0.954 0.671 0.079

3.Breakingyourarm 3.27 1.051 −0.372 −0.502

4.Cuttingyourtonguelickinganenvelope 2.23 1.059 0.660 −0.266

5.Havingaheavyobjecthityouinthehead 3.56 1.035 −0.462 −0.349

6.Breakingyourleg 3.50 1.022 −0.505 −0.246

7.Hittingasensitiveboneinyourelbow-your“funnybone” 2.36 1.025 0.367 −0.534 8.Havingabloodsampledrawnwithahypodermicneedle 2.02 1.108 0.961 0.108 9.Havingsomeoneslamaheavycardooronyourhand 3.48 1.021 −0.429 −0.296

10.Fallingdownaflightofconcretestairs 3.45 0.952 −0.395 −0.204

11.Receivinganinjectioninyourarm 1.76 0.921 1.367 1.843

12.Burningyourfingerswithamatch 2.17 0.975 0.774 0.296

13.Breakingyourneck 4.34 0.942 −1.699 2.726

14.Receivinganinjectioninyourhip/buttocks 2.09 1.056 0.809 −0.010 15.Havingadeepsplinterinthesoleofyourfootprobedandremovedwithtweezers 2.63 0.995 0.263 −0.492 16.Havinganeyedoctorremoveaforeignparticlestuckinyoureye 3.13 1.147 −0.049 −0.844

17.Receivinganinjectioninyourmouth 2.72 1.154 0.235 −0.741

18.Beingburnedonyourfacebyalitcigarette 3.40 1.040 −0.293 −0.522

19.Gettingapaper-cutonyourfinger 1.92 0.868 0.856 0.535

20.Receivingstitchesinyourlip 3.09 1.041 −0.036 −0.576

21.Havingafootdoctorremoveawartfromyourfootwithasharpinstrument 2.71 1.035 0.167 −0.569 22.Cuttingyourselfwhileshavingwithasharprazor 1.85 0.850 0.976 0.886

23.Gulpingahotdrinkbeforeithascooled 2.02 0.849 0.576 −0.089

24.Gettingstrongsoapinbothyoureyeswhilebathingorshowering 1.93 0.869 0.873 0.700 25.Havingaterminalillnessthatcausesyoudailypain 4.54 0.792 −1.920 3.648

26.Havingatoothpulled 2.61 1.074 0.276 −0.545

27.Vomitingrepeatedlybecauseoffoodpoisoning 2.74 1.004 0.079 −0.479

28.Havingsandordustblowintoyoureyes 2.27 0.943 0.597 0.052

29.Havingoneofyourteethdrilled 2.52 1.017 0.332 −0.413

30.Havingamusclecramp 2.23 0.978 0.563 −0.160

Items12,22,and24wereexcludedfromthemodel,because theyshowedfactorloadingsbelow0.50anddoublesaturation withdifferencessmallerthan0.10betweentwofactors.

Internalconsistency

Subscale–subscaleintercorrelations

There are positive and significant correlations among all subscales.Specifically,medicalpainsubscaleisstrongly cor-related with the injection pain subscale, r(1094)=0.59 and afflictedpainsubscale,r(1094)=0.58.Severepainsubscaleis stronglycorrelatedwithmedicalpainsubscale,r(1094)=0.54, withminor painsubscale, r(1094)=0.49, withafflictedpain subscale, r(1094)=0.45, and with injection pain subscale, r(1094)=0.30.Minorpainsubscaleisstronglycorrelatedwith medicalpainsubscale,r(1094)=0.57,withafflictedpain sub-scale, r(1094)=0.52, and is also correlated with injection painsubscale,r(1094)=0.41.Injectionpainsubscaleis posi-tivelyandsignificantlycorrelatedwithafflictedpainsubscale, r(1094)=0.44(forallcorrelations,p<0.01).

Subscale–totalscoreintercorrelations

Therearealsopositiveandsignificantcorrelationsbetween totalscore and subscales:severe pain, r(1094)=0.78, minor pain,r(1094)=0.77,medicalpain,r(1094)=0.85,injectionpain, r(1094)=0.68,andwithafflictedpainsubscale,r(1094)=0.76.

Cronbach’salpha

Theinternalconsistencyofthesubscaleswiththeitemsthat resultedfrom theexploratoryfactorialanalysiswas˛ =0.81 for minor pain subscale, ˛ =0.85 for severe pain subscale,

˛ =0.80formedicalpainsubscale, ˛ =0.83forinjectionpain subscale,and˛ =0.75forafflictedpainsubscale.Overallalpha was˛ =0.92.

Calculationofreliabilitybythemethodofbipartition

The reliability index was also calculated by the biparti-tion method, with the following results: for total scale, r(1094)=0.86; for minor pain subscale, r(1094)=0.78; for severepainsubscale,r(1094)=0.81;formedicalpainsubscale, r(1094)=0.77;forinjectionpainsubscale,r(1094)=0.80;andfor afflictedpainsubscale,r(1094)=0.78.

Discussion

Table2–Factorloadingsofthefive-factorsmodeloftheFearofPainQuestionnaire(FPQ-III).

Items Minorpain Severepain Injectionpain Medicalpain Afflictedpain

2.Bitingyourtonguewhileeating. 0.700 7.Hittingasensitiveboneinyourelbow-your

“funnybone”

0.665

4.Cuttingyourtonguelickinganenvelope 0.662 19.Gettingapaper-cutonyourfinger 0.649 23.Gulpingahotdrinkbeforeithascooled 0.636 24.Gettingastrongsoapintobotheyeswhiletaking

abathorshower.

0.562 0.507

22.Cuttingyourselfwhileshavingwithasharprazor 0.500 0.417

12.Burningyourfingerswithamatch 0.408 0.311

6.Breakingyourleg. 0.770

3.Breakingyourarm. 0.743

13.Breakingyourneck. 0.732

5.Havingaheavyobjecthityouinthehead 0.636 10.Fallingdownaflightofconcretestairs 0.629

1.Beinginanautomobileaccident 0.600

25.Havingaterminalillnessthatcausesyoudaily pain

0.512

9.Havingsomeoneslamaheavycardooronyour hand

0.503

11.Receivinganinjectioninyourarm 0.847

8.Havingabloodsampledrawnwithahypodermic needle

0.813

14.Receivinganinjectioninyourhip/buttocks 0.767

17.Receivinganinjectioninyourmouth 0.523

16.Havinganeyedoctorremoveaforeignparticle stuckinyoureye

0.628

20.Receivingstitchesinyourlip 0.595

18.Beingburnedonyourfacebyalitcigarette 0.585

21.Havingafootdoctorremoveawartfromyour footwithasharpinstrument

0.541

15.Havingadeepsplinterinthesoleofyourfoot probedandremovedwithtweezers

0.500

29.Havingoneofyourteethdrilled 0.694

27.Vomitingrepeatedlybecauseoffoodpoisoning 0.640

26.Havingatoothpulled 0.608

28.Havingsandordustblowintoyoureyes 0.594

30.Haveamusclecramp 0.505

change, and greater self-efficacy.34 _{Thus,the development,} adaptation,andvalidationofevaluationtoolstargetedtofear ofpainareanimportantstepinthesubjective conceptualiza-tionoftheexperienceofpain.Forallthesereasons,primarily thisstudyaimedtoadapttotheEuropeanPortugueseidiom theFPQ-IIIquestionnaireandtoexploresomeofthe psycho-metricpropertiesofonethemoreappliedquestionnairesin thisfield.20

Basedonourresults,itwasfoundthattheEuropean Por-tugueseversion does notreplicatethe three factorsmodel (minorpain,severepain,medicalpain)proposedinthe origi-nalscale.Thisresultwasexpected,sinceseveralstudieshave shownthatthethree-factormodelwith30itemsisnotthe bestadjustedone.21,23,35,36

As for the internal consistency of FPQ-III,20 _Cronbach’s alphavaluesbetween 0.87and 0.92 forthe totalscale and subscaleswerefoundintheoriginalstudy.20_{Inotherstudies,} includingotherfactorialmodels,21–23,35,36_{thereportedvalues}

remainnearandabove0.70,asrecommended.37 _Alongthe

sameline,theEuropeanPortugueseversionofFPQ-III20_with 27itemsshowedalphavaluesof0.85(Severepainsubscale)

and0.92(totalscale).Aspartofthecorrelationsbetweenthe scoresofthesubscales,andofsubscalesregardingthetotal scalescore,thesevaluesarealsosimilartothosereportedin otherstudies,20,23,35_{andevenslightlyhigher.}

elderly,peoplewithfeweryearsofformaleducation,and clin-icalpopulations). Basedonthesepoints,onecanachieve a moresystematicviewontheinfluenceofclinicaland sociode-mographic variables in the context ofFPQ-III20 _{and, more} generally,inthefearofpaindomain.

Inaddition,itisimportanttorememberthatthisisthefirst studyofFPQ-III20_{inwhichthedatawerecollectedthrough} asampleoftheInternet–andthisalsohasitsadvantages anddisadvantages.38_{Ontheonehand,itisrecognizedthat} datacollectiononlineisauseful methodologythat,in con-trasttotraditionalapproaches,facilitatesdatacollectionin termsoftimeandcostsandalsoallowawider dissemina-tionofthestudy.Ontheotherhand,inrelativeterms,itis expectedthat the percentage ofadherence to the study is lowerandthatthesampleislessrepresentativeofthe popula-tion,sincethereisthepossibilityofabiasforparticipantswith highereducation levelsand greater accesstotechnological tools,39_{which,moreover,seemstohaveoccurredinthisstudy.} However,itisimportanttostressthat theresultsobtained overtheinternet,andthoseobtainedthroughaface-to-face interactioncanbesubstantiallydifferentfromeachother,39,40 butalsoveryalike,41_{becausethisdynamicprocessdepends} onfactorssuchasthesubjectunderstudy,thetargetofthe investigation,itsmethodologyand theinstrumentsused.It isthereforestressedthattheresultsreportedherepresented severalpoints ofconvergencewith otherstudies that have implemented a traditionalapproach to a face-to-face data collectionmethodology,especiallyintermsoftheresults con-cerningthefactorialstructure,internalconsistency,andthe correlationbetweenthetotalscaleandsubscales.Forallthat, thedataobtainedthroughtheonlineadministrationappear tobecomparabletoaface-to-facemethodology.

Inconclusion, this study sought toprovide dataon the EuropeanPortugueseadaptationofFPQ-III,20 _{intheface of} the relevance given to the fear of pain under the pain of fear-avoidancemodel,3,4_{whichhasbeenreflectedintermsof} developmentofanumberofstudiesonevaluationand inter-ventionprocesses,takingintoaccountthepossibleroleofthis variableinchronicpain.16,19_{Thequestionnaireisconsistent,} thatis,allitemsmeasurethesamethingwithindefined fac-tors;moreover,thistoolseemstobereliable,asitsreliability indicesareacceptable.Inthiscontext,FPQ-III20 _hasseveral advantages;forinstance,20,23_{thisisashort,easy-to-applyand} tovaluatetool,which canbeusedbothinclinicalsettings andinresearch;itcanhelptoidentifypeoplewhosefearof paincaninterferewiththerecoveryandinterventionprocess, aswellaspeoplewithchronicpainwhoexperienceahigh fearofthepainitself;thequestionnairecanhelptoseparate groupsofpeoplewithlower/higherfearofpain;itcanbeused inconjunctionwithothertoolsandmethodologiesto antici-patewhichpeoplehaveapotentialfordevelopingchronicpain conditions,thusadjustingtheappraisal/interventionprocess. Nevertheless,itiscriticaltopointoutthatFPQ-III20_shouldbe usedincombinationwithothertoolsintermsofassessment andintervention,bothbecauseitisaself-reportmeasure(as weareevaluatingasubjectiveexperiencethatcanbe overes-timatedorunderestimated),andbecausewearedealingwith aconstructwhose characteristics,directionality,and impli-cationsare notentirely clear withinthe development and maintenanceofchronicpain.15_{Still,FPQ-III,}20_{incombination}

withothertools,maybeusefulindevelopingassessmentand

intervention procedures progressively morecomprehensive

andtailoredtothechallengesraisedbytheissueofchronic pain.

Funding

Thisstudywassupportedbyanindividualdoctoral scholar-ship grantedbythe PortugueseFoundationforScienceand Technology(Reference:SFRH/BD/80389/2011).

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

TheauthorswouldliketothankSusanaBarros,Carina Fernan-des,andJoanaMelofortheircollaborationinthetranslation processoftheinstrumentfortheEuropeanPortugueseidiom, aswellasDianaMoreiraforguidingintheadjustment pro-cedures. Similarly,aspecial thanksgoes toall participants involvedinthisstudy.

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