Initial psychometric evaluation of the Portuguese version of the Canine Brief Pain Inventory

João C. Alves Divisão de Medicina Veterinária, Guarda Nacional Republicana (GNR), Lisbon, Portugal
MED–Mediterranean Institute for Agriculture, Environment and Development, Instituto de Investigação e Formação Avançada, Universidade de Évora, Pólo da Mitra, Évora, Portugal

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Ana Santos Divisão de Medicina Veterinária, Guarda Nacional Republicana (GNR), Lisbon, Portugal

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Patrícia Jorge Divisão de Medicina Veterinária, Guarda Nacional Republicana (GNR), Lisbon, Portugal

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Abstract

OBJECTIVE

To perform the initial psychometric evaluation of the Portuguese version of the Canine Brief Pain Inventory (CBPI).

ANIMALS

A total of 100 dogs, 50 with bilateral hip osteoarthritis and 50 unaffected dogs.

PROCEDURES

The 2 groups of dogs were assessed using the CBPI. The English version of the CBPI (divided into a pain severity score and a pain interference score) was translated into Portuguese, and a copy of the translated version was completed by native Portuguese speakers’ canine handlers. The results from the 2 groups were compared, and psychometric properties were evaluated. Construct validity was evaluated by assessing differences between animals with osteoarthritis and unaffected animals with the Mann-Whitney test. Further evaluation was performed with the Kaiser-Meyer-Olin measure of sampling adequacy, Eigenvalue, and scree-plot analysis. Internal consistency was tested with Cronbach α.

RESULTS

A significant difference was observed between dogs with osteoarthritis and unaffected dogs in pain severity and pain interference scores (P < .01 for both), one indication of construct validity. Cronbach α was 0.99, and a high interitem correlation was observed, showing strong internal consistency. One factor accounted for 92.3% of the total variance.

CLINICAL RELEVANCE

We presented the initial validation of the Portuguese version of the CBPI and its validity in the Portuguese language. It is an essential step in providing a valid tool for clinicians to assess pain in dogs with osteoarthritis. Further studies are required to determine if the present results can be replicated across samples with different characteristics and evaluate response to treatment.

Abstract

OBJECTIVE

To perform the initial psychometric evaluation of the Portuguese version of the Canine Brief Pain Inventory (CBPI).

ANIMALS

A total of 100 dogs, 50 with bilateral hip osteoarthritis and 50 unaffected dogs.

PROCEDURES

The 2 groups of dogs were assessed using the CBPI. The English version of the CBPI (divided into a pain severity score and a pain interference score) was translated into Portuguese, and a copy of the translated version was completed by native Portuguese speakers’ canine handlers. The results from the 2 groups were compared, and psychometric properties were evaluated. Construct validity was evaluated by assessing differences between animals with osteoarthritis and unaffected animals with the Mann-Whitney test. Further evaluation was performed with the Kaiser-Meyer-Olin measure of sampling adequacy, Eigenvalue, and scree-plot analysis. Internal consistency was tested with Cronbach α.

RESULTS

A significant difference was observed between dogs with osteoarthritis and unaffected dogs in pain severity and pain interference scores (P < .01 for both), one indication of construct validity. Cronbach α was 0.99, and a high interitem correlation was observed, showing strong internal consistency. One factor accounted for 92.3% of the total variance.

CLINICAL RELEVANCE

We presented the initial validation of the Portuguese version of the CBPI and its validity in the Portuguese language. It is an essential step in providing a valid tool for clinicians to assess pain in dogs with osteoarthritis. Further studies are required to determine if the present results can be replicated across samples with different characteristics and evaluate response to treatment.

Osteoarthritis (OA) is a common disease in companion animal medicine and constitutes the common endpoint of several joint disorders.1 The hip joint is commonly affected, particularly in large, active dogs, and both joints are usually affected.2,3 Pain is generally considered the most significant OA clinical sign. Many of the therapeutic approaches to the OA patient still aim to manage pain.4,5 Pain is not directly measurable, and in dogs, OA-related chronic pain is considered underdiagnosed and poorly managed.6,7 For that reason, it is crucial to have properly constructed and validated outcome measures to evaluate patients and their response to treatment.8 With that goal in mind, several clinical metrology instruments have been developed to measure pain.9,10

The Canine Brief Pain Inventory (CBPI) is a clinical metrology instrument commonly used to evaluate pain and is recommended in the veterinary literature to evaluate pain in individuals or groups.11,12 It can differentiate between the effects of a treatment and a placebo in animals with OA, with results correlating with objective measures.1316 The CBPI has not been associated with response bias and may be used as a clinical outcome measure in dogs with OA-associated chronic pain, treated with pharmacological and nonpharmacological interventions.17 It is composed of 10 questions or items, divided into 2 sections, a pain severity score (PSS) that assesses the magnitude of an animal’s pain and a pain interference score (PIS) that evaluates the degree to which pain affects daily activities.18 The PIS was suggested as being more sensitive than PSS in assessing treatment results, maybe because the interference questions are more specific19. In addition to these 2 sections, there is a single final quality of life question, aimed at evaluating the owner’s overall assessment of the dog’s status.20

The process for developing a questionnaire has been described in the literature, with validity being determined through different approaches. Face validity is judged by a group of experts who evaluate if the outlined scale reasonably resembles the goal of the questionnaire. Construct validity is evaluated when the target attribute, as is the case of pain, cannot be observed directly.20 This means that it evaluates the construction of the tool to be equal to the construction of what it measures. An additional measure of validity is convergent validity, assessed by the degree to which the theoretical relation between 2 measures actually occurs, as is the case for “pain” and “quality of life,” which should be inversely related.20 It is also required to evaluate the questionnaire’s reliability by determining if it delivers consistent results.20 This process of applying specific research methods to evaluate an instrument’s validity and reliability is called psychometric testing.21

These properties have to be assessed after the translation of the questionnaire to the target language and applied to the target population.8 The translation of the CBPI into Portuguese, a language spoken by 261 million people around the world,22 would allow its use in a broad set of clinical settings with a large target population.

We aimed to validate a Portuguese version of the Canine Brief Pain Inventory, allowing its use in studies where the target population has Portuguese as a primary language. We hypothesized that the Portuguese version would show the reliability and validity documented in the English version.

Materials and Methods

The study protocol was approved by the ethical review committee of the University of Évora (Órgão Responsável pelo Bem-estar dos Animais da Universidade de Évora, approval No. GD/37187/2021/P1) and complied with the relevant institutional and national guidelines for the care and use of animals. The Animal Research: Reporting of In Vivo Experiments (ARRIVE) guidelines for reporting were followed. Written, informed consent was obtained from the institution responsible for the animals. Written permission to translate the CBPI into Portuguese was obtained. A bilingual researcher, native-speaker of the target language, translated the English version into Portuguese. This version was then translated back into the original language by a different bilingual reviewer, with native-level English proficiency. The 2 versions were then compared for accuracy, until a consensus on the final translated version was reached. This pilot study was not included in the present report.23

The CBPI comprises 10 items, with 4 questions corresponding to the PSS and 5 to the PIS. The response to each question corresponds to a score ranging from 0 to 10. For the PSS, 0 represents a level of no pain, and 10 represents extreme pain. For the PIS, 0 represented a level of no interference and 10 of complete interference.20 Additionally, a single quality of life question is presented at the end of the questionnaire. The original version of the CBPI is freely available online (https://www.vet.upenn.edu/docs/default-source/VCIC/canine-bpi.pdf?sfvrsn=6fd20eba_0; Appendix). The Portuguese version of the Canine Brief Pain Inventory is shown in Table 1.

Table 1

Portuguese version of the Canine Brief Pain Inventory.

Canine Brief Pain Inventory
Descrição da dor:
Observe a dor do seu cão:
Sem dor Dor extrema
   Escolha o valor que melhor identifica a dor do seu cão no seu pior nos últimos 7 dias. 0 1 2 3 4 5 6 7 8 9 10
   Escolha o valor que melhor identifica a dor do seu cão no seu melhor estado nos últimos 7 dias. 0 1 2 3 4 5 6 7 8 9 10
   Escolha o valor que melhor identifica a dor média do seu cão nos últimos 7 dias. 0 1 2 3 4 5 6 7 8 9 10
   Escolha o valor que melhor identifica a dor seu cão neste momento. 0 1 2 3 4 5 6 7 8 9 10
Descrição da locomoção:
Escolha o valor que melhor identifica o quanto a dor interferiu, nos últimos 7 dias:
Não interferiu Interferiu completamente
   Com a actividade geral do seu cão 0 1 2 3 4 5 6 7 8 9 10
   Com o usufruto da vida do seu cão 0 1 2 3 4 5 6 7 8 9 10
   Com a capacidade do seu cão se levantar quanto está deitado 0 1 2 3 4 5 6 7 8 9 10
   Com a capacidade do seu cão andar 0 1 2 3 4 5 6 7 8 9 10
   Com a capacidade do seu cão correr 0 1 2 3 4 5 6 7 8 9 10
   Com a capacidade do seu cão subir (p.e. escadas) 0 1 2 3 4 5 6 7 8 9 10
Descrição da locomoção:
   Escolha a resposta que melhor identifica a qualidade de vida de um modo geral do seu cão, nos últimos 7 dias. Excelente Muito boa Boa Razoável

A convenience sample of 100 police working dogs was selected, where 50 dogs had bilateral hip OA, and 50 were unaffected dogs. All were examined, and the diagnosis of hip OA was based on consistent patient history (difficulty rising, jumping, and stiffness), physical examination (joint pain and reduced range of motion), and radiographic findings (Orthopedic Foundation for Animals hip scores of mild, moderate, or severe). We also set as additional inclusion criteria a body weight ≥ 20 kg, an age > 2 years, and for dogs with OA a period > 6 weeks without receiving any medication or nutritional supplements. All inclusion criteria had to be met for an animal to be included in the study. All animals were submitted to a physical, orthopedic, and neurological examination, complete blood count, and serum biochemistry to rule out other possible diseases.24 The canine handlers, a different one for each dog, completed a copy of the Portuguese version of the CBPI in a quiet room with as much time as needed to answer all items. All handlers were native Portuguese speakers.

Statistical analysis

Construct validity was evaluated by comparing unaffected and osteoarthritic animals’ scores with the Mann-Whitney test. Additionally, validity testing was performed through factor analysis, which explores the relationship between the different questions of the instrument,25 using the Kaiser-Meyer-Olin measure of sampling adequacy, with adequacy considered > 0.6. Eigenvalue and scree-plot analysis were used to assess extracted values, and item loading on the extracted components was based on a varimax-rotated model of factor analysis, with a considered communality cut-off value of 0.4. Correlation between items was assessed with Spearman’s rank correlation coefficient, P < .05. Internal consistency was tested to evaluate the consistency of observed results with Cronbach α for the PSS and PIS, with a value of at least 0.8 being considered reliable.8,14,20 All data were analyzed with IBM SPSS Statistics version 20.

Results

The sample included 100 police working dogs, with a mean body weight of 24.1 ± 7.2 kg, a body condition score of 4/9,26 and an age of 7.4 ± 3.2 years. Both sexes were represented, with 55 males and 45 females, and 4 different breeds: German Shepherd Dogs (n = 34), Belgian Malinois Shepherd Dogs (30), Labrador Retriever (20), and Dutch Shepherd Dog (16).

A significant difference was observed between osteoarthritic and unaffected dogs in PSS, PIS, and the quality of life question (P < .01 for all), with osteoarthritic dogs showing higher CBPI scores. The results obtained for each item of the questionnaire, for dogs with OA and healthy dogs, are presented in Table 2.

Table 2

Results (mean and SD, minimum and maximum) for each item of the Portuguese version of the Canine Brief Pain Inventory, for dogs with osteoarthritis (OA) and healthy dogs.

Mean SD Min Max
Item OA Healthy OA Healthy OA Healthy OA Healthy
PSS
   Worst pain 3.22 0.13 1.94 0.12 1 0 7 1
   Least pain 3.53 0.00 2.09 0.00 1 0 7 0
   Average pain 3.37 1.00 1.9 0.05 1 0 7 1
   Pain now 3.39 0.00 1.99 0.00 1 0 7 0
PIS
   Activity 3.27 0.00 2.04 0.00 1 0 7 0
   Enjoyment 3.61 0.00 2.31 0.00 1 0 7 0
   Rising 3.14 0.00 2.04 0.00 1 0 7 0
   Walking 3.73 0.00 2.43 0.00 1 0 7 0
   Running 3.82 0.00 2.49 0.00 1 0 8 0
   Climbing 3.94 0.00 2.56 0.00 1 0 9 0

Kaiser-Meyer-Olkin factor analysis was 0.96. As all values were above 0.8, factor analysis was conducted. The varimax-rotated factor analysis model identified one factor with an eigenvalue > 1, accounting for 92.3% of the variance. The remaining factors have eigenvalues < 0.3. A scree-plot confirmed the retention of that one factor, the only one with an eigenvalue > 1. Based on the varimax-rotated solution, loading for this item was performed. All items loaded heavily on the first component, with commonalities ranging between 0.79 and 0.98.

Cronbach α was 0.99, and a high interitem correlation was observed. PSS and PIS showed a high correlation (0.97) and negative correlation with the quality of life item (−0.75 and −0.81, respectively, with P < 0.01 for both). The overall results of factor loadings and communality of each item of the Portuguese version of the Canine Brief Pain Inventory, and Cronbach α and interitem correlation of each item, the pain severity and pain interference domains, and of the total instrument are presented in Table 3.

Table 3

Factor loadings and communality of each item of the Portuguese version of the Canine Brief Pain Inventory, and Cronbach α and interitem correlation of each item, the pain severity and pain interference domains, and of the total instrument.

Factor and Items Factor loading Communality Cronbach α Interitem correlation
Pain severity 0.95 0.98
   Worst pain 0.84 0.94 0.97 0.95
   Least pain 0.75 0.98 0.85 0.94
   Average pain 0.75 0.96 0.88 0.93
   Pain now 0.83 0.93 0.91 0.93
Pain interference 0.97 0.94
   Activity 0.84 0.95 0.96 0.87
   Enjoyment 0.41 0.89 0.96 0.97
   Rising 0.88 0.94 0.95 0.88
   Walking 0.54 0.81 0.95 0.81
   Running 0.72 0.79 0.94 0.83
   Climbing 0.86 0.88 0.97 0.90
Total Instrument 0.99

Discussion

The translation of the CBPI into Portuguese is a further step in increasing the availability of this validated instrument to a broader audience and opening its use for daily practice and research. It will also allow for cooperation in international studies and to compare the results of different studies.20 This study shows that the Portuguese version of the CBPI has an adequate internal consistency and construct validity in dogs with bilateral hip OA, similar to what has been described before for the original English version and other translated versions.8,14,20

When evaluating a questionnaire, assessing its validity helps to determine if it is measuring what it is supposed to measure.7,14 By comparing the results of unaffected and osteoarthritic dogs, we observed that the CBPI could differentiate between them. These PIS and PSS components have high correlation coefficients, and it is reasonable to assume that “pain,” as captured with the CBPI, might correlate with lameness.14 Our results also support this, as the PSS and PIS have a high correlation that, as expected, is negatively correlated with the quality of life item. This finding is consistent with the findings for the English, French, and Italian versions,20,27,28 confirming that higher pain is related to poorer dog’s quality of life, showing convergent validity.

One of the ways to evaluate construct validity is through factor analysis, and Cronbach α is most frequently used to test internal consistency.7,10,14 Our results for factor analysis, and for scree-plot analysis, extracted one component with eigenvalues > 1, the same number of components as in previous reports.8,14 Item loading of the components for CBPI identified items that could be described with the “worst level of pain.”

It is interesting to see similar results between different reports, as it is not uncommon to obtain different factor analysis results for different populations. In particular, we must keep in mind that this study’s sample was composed of a relatively homogenous group. Animals selected represented a small number of breeds, housed in similar kennels, and receiving the same feeding. In addition, they spend most of the working day involved in activities with their handlers, training, and exercising. Importantly, all OA animals had exclusively bilateral hip OA. Still, the results from this test were similar to those obtained with populations of companion dogs, which may be attributed to a consistent behavior of the CBPI when applied to different populations. When differences are detected, a possible reason is the variable ability of different people to detect clinical signs to complete the questionnaire.29,30 Signs of pain and pain expression can sometimes be very subtle,31 particularly in working dogs, which usually do not show overt signs of pain.32 The dog’s handlers who completed the CBPI are experienced professionals who receive frequent training on early disease signs and welfare. They should be sensitive to detecting dogs’ signs, especially if it is their own dog. Still, no differences were observed compared to previous reports, where the dogs’ owners completed the questionnaire. This may indicate that the CBPI can be used when evaluating working and companion dogs, both kenneled and at home.

Factor loading was also supported by the good interitem correlations and good Cronbach α.20 Our results for Cronbach α values were higher than the ones from previous reports.14,20,33 It is not surprising that Cronbach α varies in performance between different populations and is possibly influenced by a homogenous sample with a low overall variance of item scores.34 This should be evaluated in future studies. Although our results validate this Portuguese version of the CBPI, they were not evaluated in comparison with an objective measure. Its properties should also be assessed in a larger population of dogs with OA from other joints, as this study’s sample was relatively homogenous. In addition, while the English version of the CBPI has been able to evaluate response to treatment12,19 and has been extensively used for that purpose,35,36 the same ability is yet to be evaluated in the Portuguese version.

In this study, we determined the initial validation of the Portuguese version of the CBPI and its validity in the Portuguese language. Further studies are required to determine if the present results can be replicated across samples with different characteristics and evaluate the response to treatment.

Acknowledgments

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

JCA designed the protocol, conducted treatment sessions, and prepared the manuscript.

PJ and AS conducted treatment sessions.

The authors thank Dr. Manuel Pereira for the assistance in the statistical analysis of the data.

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Appendix 1

English version of the Canine Brief Pain Inventory.

Canine Brief Pain Inventory
Description of pain:
Rate your dog’s pain:
No pain Extreme pain
 1. Choose the one number that best describes the pain at its worst in the last 7 days. 0 1 2 3 4 5 6 7 8 9 10
 2. Choose the one number that best describes the pain at its least in the last 7 days 0 1 2 3 4 5 6 7 8 9 10
 3. Choose the one number that best describes the pain at its average in the last 7 days. 0 1 2 3 4 5 6 7 8 9 10
 4. Choose the one number that best describes the pain as it is right now. 0 1 2 3 4 5 6 7 8 9 10
Description of function:
Choose the one number that best describes how during the last 7 days pain has interfered with your dog’s:
Does not interfere Completely interferes
 5. General Activity 0 1 2 3 4 5 6 7 8 9 10
 6. Enjoyment of Life 0 1 2 3 4 5 6 7 8 9 10
 7. Ability to Rise to Standing From Lying Down 0 1 2 3 4 5 6 7 8 9 10
 8. Ability to Walk 0 1 2 3 4 5 6 7 8 9 10
 9. Ability to Run 0 1 2 3 4 5 6 7 8 9 10
10. Ability to Climb Stairs, Curbs, Doorsteps, etc. 0 1 2 3 4 5 6 7 8 9 10
Overall impression:
11. Choose the answer that best describes your dog’s overall quality of life over the last 7 days. Poor Fair Good Very good Excellent
All Time Past Year Past 30 Days
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