Cross-Cultural Adaptation and Psychometric Validation of the Chinese Version of the Douleur Neuropathique 4 Questionnaire in Patients with Knee Osteoarthritis

Cross-Cultural Adaptation and Psychometric Validation of the Chinese Version of the Douleur Neuropathique 4 Questionnaire in Patients with Knee Osteoarthritis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Cross-Cultural Adaptation and Psychometric Validation of the Chinese Version of the Douleur Neuropathique 4 Questionnaire in Patients with Knee Osteoarthritis Xiaofeng Chang, Shuxin Yao, Jie Wei, Lei Shang, Chao Xu, Jianbing Ma This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6881253/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Knee osteoarthritis (KOA) patients frequently continue to experience persistent pain and functional limitations following total knee arthroplasty (TKA), posing substantial challenges for postoperative pain management. Accurate preoperative characterization of pain profiles is therefore essential for devising individualized treatment strategies. The Douleur Neuropathique 4 Questionnaire (DN4) is a concise, validated instrument for detecting neuropathic pain components and has demonstrated robust reliability and validity across diverse cultural settings. However, to date no culturally adapted Chinese version is available. This study aimed to translate and culturally adapt the DN4 into Chinese (DN4-CV) and to evaluate its psychometric properties in a cohort of Chinese KOA patients undergoing TKA. Methods Following established cross-cultural adaptation guidelines, the original DN4 was forward- and back-translated by bilingual experts, harmonized by a multidisciplinary panel, and piloted in 50 KOA patients. The finalized Chinese DN4 (DN4-CV) was administered to 335 KOA outpatients. Psychometric properties were assessed via internal consistency (Cronbach’s α), test–retest reliability (intraclass correlation coefficient, ICC), exploratory factor analysis (EFA) for structural validity, and receiver operating characteristic (ROC) analysis. The optimal cutoff score was determined by maximizing Youden’s index. Results The DN4-CV demonstrated good internal consistency (α = 0.805) and excellent test–retest reliability (ICC = 0.973). EFA identified two factors accounting for 56.32% of total variance. ROC analysis yielded an area under the curve of 0.979 (95% CI: 0.962–0.996). Using a cutoff score ≥ 4, sensitivity was 99.0%, specificity 96.4%, positive predictive value 97.5%, negative predictive value 98.5%, and overall accuracy 97.9%. Conclusions The DN4-CV is a reliable, valid, and highly accurate tool for screening neuropathic pain in KOA patients, supporting its clinical utility for early identification and individualized pain management. Knee osteoarthritis Neuropathic pain DN4 questionnaire Cross-cultural adaptation Psychometric validation Introduction Knee osteoarthritis (KOA) is the most prevalent degenerative joint disease among the elderly, characterized by joint pain, stiffness, and functional impairment, which significantly compromises quality of life [ 1 , 2 ] . Traditionally, KOA pain has been attributed to mechanical loading and joint inflammation, and therefore classified as nociceptive pain [ 3 ] . However, accumulating evidence indicates that a subset of KOA patients exhibit neuropathic pain (NeP) features—such as burning sensations, electric shock–like pain, paresthesia, and mechanical allodynia—suggesting involvement of peripheral or central nervous system alterations [ 4 , 5 ] . Neuropathic pain is often refractory to conventional therapies [ 6 ] , and failure to recognize its presence preoperatively may increase the risk of persistent postoperative pain and delay rehabilitation [ 7 , 8 ] . Early identification of neuropathic pain components is therefore crucial for personalized pain management and surgical planning in KOA [ 9 ] . Among the screening instruments developed for neuropathic pain, the DN4—developed by the French Neuropathic Pain Group—has gained widespread use due to its brevity, ease of administration, and diagnostic accuracy. The DN4 comprises seven symptom-based items and three clinical examination items, and has demonstrated a sensitivity of 83% and specificity up to 90% for detecting neuropathic pain [ 10 ] . Since its introduction, the DN4 has been translated into and validated in multiple languages, including Korean, Japanese, Spanish, Persian, Arabic, Greek, and Dutch [ 11 – 17 ] , and has shown robust psychometric properties in conditions such as diabetic polyneuropathy, post-herpetic neuralgia, and spinal cord injury–related pain [ 18 , 19 ] . Despite its extensive international application, there is currently no validated Chinese version of the DN4 tailored for KOA populations. Given the potential impact of linguistic structures and cultural nuances—particularly in symptom description and patient–clinician communication—direct adoption of a foreign-language version may undermine measurement accuracy and compromise clinical assessment and intervention decisions. Consequently, cross-cultural adaptation of the DN4 into Chinese for KOA patients (DN4-CV) is essential to ensure reliable identification of neuropathic pain components in this cohort. This study therefore aims to bridge this gap by cross-culturally adapting and validating the DN4 questionnaire according to the internationally recognized guidelines of Beaton et al. [ 20 ] , and by evaluating its reliability, validity, and discriminative capability in a cohort of Chinese KOA patients. Through this work, we intend to provide a scientifically robust and clinically practical tool for screening neuropathic pain in KOA, ultimately facilitating early detection and individualized pain management. Materials and methods Translation and cross-cultural adaptation This study adhered to established guidelines for translation and cross-cultural adaptation, comprising five consecutive steps [ 20 ] . First, two bilingual native Chinese speakers fluent in English independently translated the original English version of the DN4 questionnaire [ 21 ] into Simplified Chinese. One translator was a pain-management specialist familiar with neuropathic pain terminology, and the other was a professional translator without a medical background, thereby ensuring both clinical accuracy and linguistic fluency. The two translations were then compared and reconciled to produce a preliminary consensus version of the Chinese DN4 (DN4-CV). Then, a multidisciplinary expert panel (including the translators, pain clinicians, a linguist, and a methodologist) convened to resolve cultural and contextual discrepancies and to refine the phrasing. Following discussion, the panel drafted the first version of the DN4-CV. During Step three, two additional bilingual translators with medical expertise, blinded to the original DN4, independently back‐translated this draft into English. The back‐translations were reviewed and synthesized, then compared with the source version by the expert committee to confirm conceptual equivalence. Minor revisions were made to enhance semantic accuracy and cultural relevance, yielding the second version of the DN4-CV. Next, the research team held a second expert meeting to review all revisions and ensure consistency across items. This step emphasized the preservation of equivalence in content, intent, and clinical interpretation between the Chinese and English versions; upon conclusion, the final DN4-CV was produced. Finally, the provisional DN4-CV was pilot‐tested in 50 patients diagnosed with knee osteoarthritis. Cognitive debriefing interviews assessed participants’ comprehension, interpretation, and perceived relevance of each item. Based on patient feedback, minor wording adjustments were made to improve clarity. The resulting version was finalized for subsequent psychometric validation (see Supplementary File 1: Appendix A). Patients Between July 2024 and May 2025, patients were consecutively recruited from the outpatient clinic of Honghui Hospital, Xi’an Jiaotong University. Eligible participants were adults (≥ 18 years) with a clinical diagnosis of knee osteoarthritis and persistent pain lasting longer than three months who were able to comprehend and complete study questionnaires. Patients were excluded if they had severe cognitive impairment or other conditions precluding understanding of the survey instruments, coexisting serious systemic illnesses, recent major knee surgery, or concurrent enrollment in other interventional trials or receipt of active pharmacological or therapeutic interventions. Study design This prospective observational study was designed to translate and cross-culturally adapt the English-language DN4 into Chinese and to evaluate its reliability and validity. Knee osteoarthritis patients were consecutively recruited from the outpatient clinic of the Affiliated Honghui Hospital of Xi’an Jiaotong University. The study was conducted in accordance with the ethical principles of the 1964 Declaration of Helsinki and its later amendments, and received approval from the Honghui Hospital Ethics Committee (Approval No. 202,407,017). Written informed consent was obtained from all participants. To determine the required sample size, we followed the guideline recommending a minimum of ten respondents per questionnaire item [ 22 ] , yielding at least 100 subjects. An a priori power analysis was also performed using G*Power version 3.1 (Düsseldorf, Germany); assuming a medium effect size (Cohen’s d = 0.5), α = 0.05, power (1–β) = 0.80, and a 1:1 allocation ratio, the minimum total sample size was calculated as 176 patients. To improve precision and allow for potential dropouts, 335 patients were ultimately enrolled, and a post hoc power analysis confirmed the adequacy of the primary statistical tests. Questionnaires All participants first completed a demographic questionnaire capturing age, sex, height, weight (for BMI calculation), education level, occupation, and living situation. They then completed the PainDETECT questionnaire (PDQ) and the EQ-5D-5L scale to assess neuropathic pain characteristics and health-related quality of life. Evaluation of neuropathic pain Clinical diagnosis served as the gold standard: experienced neurologists, pain specialists, and orthopedic surgeons classified each patient’s pain as Nep or Np based on medical history, physical examination, electromyography, or imaging studies. All enrolled patients underwent this expert evaluation to confirm their pain category. Douleur Neuropathique 4 Questionnaire (DN4) The DN4 was originally developed and validated in French and comprises ten items across four domains: seven items evaluate pain quality, while three clinical examination items assess hypoesthesia to touch and pinprick. Responses are “yes” or “no,” scored 1 and 0 respectively; the total score is the sum of all items, with a cutoff of ≥ 4/10 indicating neuropathic pain [ 10 ] . PainDETECT questionnaire (PDQ) The PDQ is an internationally recognized screening tool for neuropathic pain containing four sections: (1) a 0–10 numerical rating scale (NRS) for pain intensity; (2) four graphic patterns to characterize pain course; (3) a body map for patients to mark pain and radiating pain locations; and (4) seven weighted sensory descriptors (e.g., burning, tingling, numbness) to refine pain characterization. The total score ranges from 0 to 38: ≤12 suggests low probability, ≥ 19 high probability of neuropathic pain, and 13–18 is indeterminate. This study used the validated Chinese version of the PDQ [ 23 ] . EuroQoL five-dimensions questionnaire (EQ-5D-5L) The EQ-5D-5L is a widely used, multidimensional health-related quality of life (HRQoL) instrument in large Chinese populations. It assesses five dimensions—mobility, self-care, usual activities, pain/discomfort, and anxiety/depression—each on a five-level scale, providing a comprehensive profile of health status [ 24 ] . Data analyses The Kolmogorov–Smirnov test was applied to examine the normality of questionnaire score distributions. Continuous variables are reported as mean ± standard deviation, and categorical variables as frequencies and percentages. Statistical analyses were conducted using SPSS version 27.0 (IBM Corp., New York), with a significance threshold set at P < 0.05. Feasibility assessment The feasibility of the questionnaire was evaluated by documenting any difficulties encountered by respondents during completion. Reliability Internal consistency, inter-rater reliability, and test-retest reliability Internal consistency was assessed using Cronbach’s α coefficient: first for the total DN4-CV scale, and then recalculated after sequentially removing each item to determine its impact on overall reliability. An α value ≥ 0.70 was considered acceptable, 0.80–0.89 good, and ≥ 0.90 excellent. To evaluate test-retest reliability, 60 patients were randomly selected from the 335 enrolled and re-administered the DN4-CV at baseline and again after 7 days [ 22 ] . Intraclass correlation coefficients (ICC) were calculated using a two-way random effects model, with ICC ≥ 0.70 indicating good reproducibility [ 25 ] . Inter-rater agreement between the DN4 classification (score ≥ 4 indicating neuropathic pain) and the clinical “gold standard” diagnosis was assessed via Cohen’s κ coefficient: κ = 0.41–0.60 denoted moderate agreement, 0.61–0.80 good agreement, and > 0.80 excellent agreement [ 26 ] . Validity Structural validity Given that factor structure may vary across populations, exploratory factor analysis (EFA) was performed to assess the structural validity of the DN4-CV. Data suitability was confirmed by a Kaiser–Meyer–Olkin (KMO) measure ≥ 0.60 and a Bartlett’s test of sphericity with P 1 (Kaiser’s criterion) and applying Varimax orthogonal rotation to clarify factor loadings. Items with absolute loadings > 0.40 were retained to ensure each contributed significantly to its respective factor, yielding an interpretable factor model [ 27 ] . Construct validity Construct validity was examined by correlating DN4-CV scores with established measures: the PainDETECT questionnaire (PDQ) and the EQ-5D-5L health index, both of which have demonstrated robust psychometric properties in Chinese populations [ 23 , 24 ] . Pearson’s correlation coefficients were interpreted as none or negligible (r = 0–0.20), weak (0.21–0.40), moderate (0.41–0.60), strong (0.61–0.80), and very strong (0.81–1.00) [ 28 ] . We hypothesized a strong positive correlation between DN4-CV and PDQ total scores, reflecting convergent validity for neuropathic pain characteristics, and a moderate inverse correlation with EQ-5D-5L, demonstrating discriminant validity with respect to health-related quality of life. ROC curve analysis Receiver operating characteristic (ROC) curve analysis was conducted to evaluate the discriminative performance of DN4-CV in diagnosing neuropathic pain. Sensitivity and specificity were calculated for each possible cut-off value, and the area under the ROC curve (AUC) quantified overall diagnostic accuracy. The optimal threshold was selected by maximizing Youden’s J index (sensitivity + specificity – 1), thereby providing the best balance of sensitivity and specificity for rapid screening of neuropathic pain in knee osteoarthritis patients [ 29 ] . Results Of the 335 evaluated patients, 195 (58.2%) were classified as having neuropathic pain (NeP) and 140 (41.8%) as nociceptive pain (NP) based on clinical diagnosis. Demographic characteristics, including sex, age, and sample composition, were comparable between the two groups (Table 1 ). Table 1 Demographic data of participants Items Neuropathic pain group (N = 195) Nociceptive pain group (N = 140) P Value Age (years, mean + SD) 65.4 ± 8.2 66.7 ± 7.2 0.131 Sex, number(%) 0.651 Women 65(33.3) 50(35.7) Men 130(66.7) 90(64.3) Height (cm, mean ± SD) 162.0 ± 7.1 162.0 ± 7.7 0.978 Weight (kg, mean ± SD) 67.1 ± 10.1 66.3 ± 11.3 0.498 Body mass index (mean ± SD) 25.5 ± 3.5 25.2 ± 3.5 0.358 Educational level, number (%) 0.544 Primary school and below 80(41) 65(46.4) Junior high school 72(36.9) 48(34.3) High school 36(18.5) 25(17.9) University or above (including junior college) 7(3.6) 2(1.4) Residence status, number (%) 0.216 Live alone 14(7.2) 12(8.6) Living with partner 118(60.5) 95(67.9) Living with children 63(32.3) 33(23.6) Employment, number (%) 0.588 Farming 170(87.2) 125(89.3) Retirement (including no longer farming) 25(12.8) 15(10.7) side, number (%) 0.707 Left 106(54.4) 79(56.4) Right 89(45.6) 61(43.6) Feasibility assessment No missing data were observed for the DN4-CV or any other questionnaire items, indicating that the instruments were well-designed and easily understood in a clinical setting. A post hoc power analysis performed with G*Power (α = 0.05, Cohen’s d = 0.5) demonstrated a statistical power of 99.8% for distinguishing NeP from Np patients. Reliability analysis The DN4-CV exhibited good internal consistency, with an overall Cronbach’s α = 0.805 (recommended threshold ≥ 0.70). Item-deleted α values ranged from 0.773 to 0.812, indicating that removal of any single item did not substantially diminish reliability. Corrected item-total correlations varied from 0.263 (Item 8) to 0.613 (Item 7), demonstrating satisfactory discriminative capacity (Table 2 ). Test–retest reliability was assessed in 60 randomly selected patients re-evaluated after 7 days: the intraclass correlation coefficient (ICC) for average measurements in a two-way mixed effects model was 0.805 (95% CI: 0.772–0.835), while the test–retest ICC was 0.973 (95% CI: 0.955–0.984); Pearson’s r between timepoints was 0.947 (p < 0.001), confirming excellent stability and reproducibility. Agreement between DN4-CV classification (score ≥ 4) and the clinical “gold standard” diagnosis was 97.9%, with Cohen’s κ = 0.957 (SE = 0.016; 95% CI: 0.926–0.988; p < 0.001). Table 2 Cronbach's Alpha to the Items of the Instrument Items Cronbach's Alpha – Removing the Item Burning 0.775 Painful sensation of cold 0.785 Electric shocks 0.782 Tingling 0.776 Pins and needles 0.785 Numbness 0.775 Itching 0.773 Hypoesthesia to touch 0.812 Hypoesthesia to prick 0.806 Brushing 0.805 Cronbach's Alpha – Total Score 0.805 Structural validity Exploratory factor analysis supported a two-factor structure for the DN4-CV. The Kaiser–Meyer–Olkin measure was 0.861 and Bartlett’s test was significant (χ² = 1004.98, df = 45, p 1 were retained, explaining 56.32% of the total variance (factor 1: 38.44%; factor 2: 17.88%). After Varimax rotation, Items 1–7 loaded strongly on factor 1 (loadings 0.542–0.799) and Items 8–10 on factor 2 (loadings 0.249–0.673), with overall loadings ranging from 0.249 to 0.799, confirming a clear and interpretable factorial structure (Table 3 ). Table 3 Factor Loadings for the DN4 Questionnaire Items (Principal Component Analysis)* Items Factor 1 Factor 2 Burning 0.768 0.055 Painful sensation of cold 0.674 0.052 Electric shocks 0.738 -0.024 Tingling 0.701 0.178 Pins and needles 0.662 0.072 Numbness 0.739 0.104 Itching 0.776 0.074 Hypoesthesia to touch 0.029 0.799 Hypoesthesia to prick 0.094 0.793 Brushing 0.106 0.786 Eigenvalue 3.844 1.788 % of Variance 38.44 17.88 Cumulative % Variance 56.32 KMO (Sampling Adequacy) 0.861 Bartlett's Test (Chi-Square) 1004.978 (p < 0.001) ∗Main components with Varimax rotation. Construct validity DN4-CV total scores correlated strongly with PDQ total scores (Pearson’s r = 0.732, p < 0.001) and moderately with EQ-5D-5L index values (r = 0.502, p < 0.001), supporting convergent and discriminant validity. Independent-samples t-tests comparing NeP (n = 195) and Np (n = 140) groups revealed highly significant differences in DN4 scores (all p < 0.001) with large effect sizes (Cohen’s d = 1.25–4.03; Tables 4 and 5 ). Table 4 Descriptive statistics for DN4 Score, PainDETECT Score and EQ-5D-5L Total Score Variable Neuropathic pain group (N = 195) Nociceptive pain group (N = 140) DN4 Score 6.9 ± 2.0 2.0 ± 1.4 PainDETECT Score 23.7 ± 3.1 10.0 ± 3.8 EQ-5D-5L Total Score 16.3 ± 2.6 13.0 ± 2.8 Data are presented as mean ± standard deviation. Table 5 Convergent and discriminant validity of the DN4 questionnaire in neuropathic pain (NeP) versus nociceptive pain (Np) groups. Validity type Variable / Comparison Statistic Value Convergent Validity DN4 and PDQ Pearson’s r (p) 0.732 DN4 and EQ-5D-5L Pearson’s r (p) 0.502 Discriminant Validity (Nep with Np) DN4 Score Mean Δ = 4.91; d = 2.75 p < 0.001 PDQ Score Mean Δ = 13.6; d = 4.03 p < 0.001 EQ-5D-5L Total Score Mean Δ = 3.34; d = 1.25 p < 0.001 Differences between patients with neuropathic pain (NeP) and those with nociceptive pain (NP) were compared using independent samples t-tests. Data are presented as follows: “Mean Δ” denotes the difference in group means NeP minus Np; “d” denotes Cohen’s d effect size (all d > 0.8, indicating large effects). Diagnostic validity (ROC curve analysis) Receiver operating characteristic analysis yielded an area under the curve (AUC) of 0.979 (95% CI: 0.962–0.996), indicating excellent discriminative accuracy of the DN4-CV. The optimal cutoff score of 3.5 (Youden’s J = 0.954) provided a sensitivity of 99.0%, specificity of 96.4%, positive predictive value of 97.5%, negative predictive value of 98.5%, and overall accuracy of 97.9% (Table 6 ). Table 6 Diagnostic performance metrics of the DN4 questionnaire in a sample Metric Value Accuracy 0.979 Sensitivity (%) 99.0 Specificity (%) 96.4 Positive predictive value (PPV) (%) 97.5 Negative predictive value (NPV) (%) 98.5 Cohen’s kappa 0.957 Data are presented as proportion or percentage as indicated. Discussion In this study, we have, for the first time in Chinese patients with knee osteoarthritis (KOA), completed the cross-cultural adaptation and psychometric validation of the Chinese version of the Douleur Neuropathique 4 questionnaire (DN4-CV), demonstrating its excellent performance for preoperative screening of neuropathic pain. The DN4-CV exhibited strong internal consistency (Cronbach’s α = 0.805), which is marginally higher than that reported for the Portuguese (α = 0.713) [ 30 ] and Spanish (α = 0.71) [ 13 ] versions, and comparable to the Korean version (α = 0.819) [ 11 ] , indicating that the core symptoms of neuropathic pain are reliably captured across different cultural contexts. Test–retest reliability was outstanding (ICC = 0.973), mirroring the Portuguese data (ICC = 0.969) [ 30 ] and confirming excellent reproducibility over a one-week interval (ICC > 0.90 is considered very high consistency). Cohen’s κ analysis further showed agreement between DN4-CV classification and the clinical “gold standard,” supporting the scale’s structural coherence and repeatability. Exploratory factor analysis (EFA) extracted two principal factors accounting for 56.32% of the total variance. Factor 1(Spontaneous Sensory Symptoms) comprised the descriptors “burning,” “painful cold,” “electric shocks,” “tingling,” “pins and needles,” “numbness,” and “itching,” reflecting small-fiber hyperexcitability or ectopic discharge commonly seen in small‐fiber dysfunction and peripheral nerve terminal sensitization. Factor 2༈Evoked Hypoesthesia༉ included the clinical examination items “hypoesthesia to touch,” “hypoesthesia to prick,” and “brushing,” representing attenuated nerve conduction combined with central sensitization. By comparison, the original French version yielded nine factors [ 10 ] , and the Portuguese version three factors explaining 57.25% of variance (loadings 0.384–0.645) [ 30 ] . The broader loading range in our study (0.249–0.799) further supports the DN4-CV’s robust structural validity. The DN4-CV demonstrated strong construct validity in our KOA cohort. Its total score correlated highly with the PDQ total score (Pearson’s r = 0.732, p < 0.001), confirming convergent validity with an established neuropathic pain measure, and showed a moderate correlation with the EQ-5D-5L index (r = 0.502, p < 0.001), supporting discriminant validity against health-related quality of life. Furthermore, when participants were stratified by the clinical “gold standard” diagnosis into Nep (n = 195) and Np (n = 140) groups, independent-samples t-tests revealed highly significant differences in DN4-CV scores (all p < 0.001) with very large effect sizes (Cohen’s d = 1.25–4.03). These results confirm that the DN4-CV not only aligns closely with other measures of neuropathic pain but also robustly distinguishes between neuropathic and nociceptive pain phenotypes, underscoring its utility as a valid screening tool. ROC curve analysis demonstrated excellent discrimination between neuropathic and nociceptive pain in KOA patients, with an AUC of 0.979 (95% CI: 0.962–0.996), exceeding the Spanish (AUC 0.85) [ 13 ] , Greek (AUC 0.89) [ 16 ] , and Dutch (AUC 0.82) [ 17 ] versions, and matching the Persian (AUC 0.97) [ 14 ] and Arabic (AUC 0.97) [ 15 ] versions. This high accuracy may reflect the homogeneity of pain phenotypes in KOA and the use of independent neurologist diagnoses as the “gold standard” to minimize bias. A cutoff of 3.5 maximized Youden’s index (0.954) with sensitivity of 99.0% and specificity of 96.4%. Originally, the DN4 demonstrated sensitivity of 82.9% and specificity of 89.9% for neuropathic pain [ 10 ] ; the Spanish version reported 79.8% and 78% [ 13 ] , and the Persian version 90% and 95% [ 14 ] . Our findings are at least equivalent, if not superior. Given the differential response of neuropathic pain to analgesics, early identification of neuropathic components is critical for tailoring chronic pain management [ 31 , 32 ] . Mixed-pain phenotypes share clinical features with pure neuropathic pain [ 13 ] , and the DN4 effectively distinguishes between them [ 33 ] . With its brevity and ease of scoring, the DN4-CV is well suited for routine outpatient screening of neuropathic pain [ 34 ] . For clinical practicality, we recommend rounding to ≥ 4, consistent with the Taiwanese [ 35 ] and Korean [ 11 ] adaptations, while retaining high sensitivity and specificity. We recommend that patients scoring ≥ 4 be targeted for early individualized pain management and postoperative interventions to optimize analgesia and improve patient satisfaction. This single-center, cross-sectional design, although conducted at the largest orthopedic center in northwest China, may limit generalizability. As a self-report instrument, the DN4-CV remains susceptible to response bias and variable comprehension. Finally, the “gold standard” was expert clinical diagnosis without adjunctive objective physiological or imaging biomarkers, leaving diagnostic validity open to further enhancement. Future multicenter, longitudinal studies incorporating objective criteria are warranted to comprehensively evaluate the DN4-CV’s reliability, validity, and responsiveness in clinical practice. Conclusion The results support the cross-cultural validity of the DN4 questionnaire: the DN4-CV demonstrates strong reliability, clear structural validity, and excellent diagnostic accuracy, and can serve as a reliable tool for screening neuropathic pain in clinical settings. Abbreviations DN4 Douleur Neuropathique 4 Questionnaire DN4-CV Chinese version of the Douleur Neuropathique 4 Questionnaire EFA Exploratory factor analysis EQ-5D-5L EuroQoL five-dimensions questionnaire ICC Intraclass correlation coefficient KOA Knee osteoarthritis NeP Neuropathic pain NP Nociceptive pain NSAIDs Nonsteroidal anti-inflammatory drugs PDQ PainDETECT questionnaire ROC Receiver operating characteristic TKA Total knee arthroplasty Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles of the Declaration of Helsinki.This prospective observational study was approved by the Medical Ethics Committee of Honghui Hospital (Approval No. 202,407,017). Informed consent was obtained from all participants involved in the study. Consent for publication Written informed consent for publication was obtained from all individual participants included in the study. Competing interests The authors declare that they have no competing interests. Funding This research was supported by the Key Research and Development Program of Shaanxi Province (2023-YBSF-464), the Cultivation Project for General Projects of Xi'an Health Commission (2024ms10), the 2024 Ministry of Education Humanities and Social Sciences Project (24YJAZH032), the Program for Innovation Team of Shaanxi Province (2023-CX-TD-73). Author Contribution CX and JBM conceived and designed the experiment. XFC,SXY, and JW collected data. XFC,CX, and JBM analyzed and interpreted the data. XFC, SXY and JW wrote the manuscript. LS and JBM modifed the manuscript. All authors read and approved the final manuscript. Acknowledgement Acknowledgments: This research was supported by the Key Research and Development Program of Shaanxi Province (2023-YBSF-464), the Cultivation Project for General Projects of Xi'an Health Commission (2024ms10), the 2024 Ministry of Education Humanities and Social Sciences Project (24YJAZH032), the Program for Innovation Team of Shaanxi Province (2023-CX-TD-73). We thank all the patients and experts who participated in the study and the individuals who helped with preparing the paper. Data Availability Availability of data and materials As the datasets will be used for future research, the datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. References Cui A, Li H, Wang D, Zhong J, Chen Y, Lu H. Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population-based studies[J]. EClinicalMedicine, 2020,29–30:100587. 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Validity and reliability of the persian (Farsi) version of the DN4 (Douleur Neuropathique 4 Questions) questionnaire for differential diagnosis of neuropathic from non-neuropathic pains[J]. Pain Pract. 2014;14(5):427–36. Harifi G, Ouilki I, El BI, Ouazar MA, Belkhou A, Younsi R, et al. Validity and reliability of the Arabic adapted version of the DN4 questionnaire (Douleur Neuropathique 4 Questions) for differential diagnosis of pain syndromes with a neuropathic or somatic component[J]. Pain Pract. 2011;11(2):139–47. Sykioti P, Zis P, Vadalouca A, Siafaka I, Argyra E, Bouhassira D, et al. Validation of the Greek Version of the DN4 Diagnostic Questionnaire for Neuropathic Pain[J]. Pain Pract. 2015;15(7):627–32. van Seventer R, Vos C, Giezeman M, Meerding WJ, Arnould B, Regnault A, et al. Validation of the Dutch version of the DN4 diagnostic questionnaire for neuropathic pain[J]. Pain Pract. 2013;13(5):390–98. Van Seventer R, Vos C, Meerding W, Mear I, Le Gal M, Bouhassira D, et al. Linguistic validation of the DN4 for use in international studies[J]. Eur J Pain. 2010;14(1):58–63. Spallone V, Morganti R, D'Amato C, Greco C, Cacciotti L, Marfia GA. Validation of DN4 as a screening tool for neuropathic pain in painful diabetic polyneuropathy[J]. Diabet Med. 2012;29(5):578–85. Beaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures[J]. Spine (Phila Pa 1976). 2000;25(24):3186–91. Van Seventer R, Vos C, Meerding W, Mear I, Le Gal M, Bouhassira D, et al. Linguistic validation of the DN4 for use in international studies[J]. Eur J Pain. 2010;14(1):58–63. Terwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J, et al. Quality criteria were proposed for measurement properties of health status questionnaires[J]. J Clin Epidemiol. 2007;60(1):34–42. Chang X, Yao S, Wei J, Shang L, Xu C, Ma J. Psychometric Characteristics of the PainDETECT Questionnaire in Patients Undergoing Total Knee Arthroplasty for Osteoarthritis[J]. J Arthroplasty, 2025. Xie S, Wang D, Wu J, Liu C, Jiang W. Comparison of the measurement properties of SF-6Dv2 and EQ-5D-5L in a Chinese population health survey[J]. Health Qual Life Outcomes. 2022;20(1):96. Koo TK, Li MY. A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research[J]. J Chiropr Med. 2016;15(2):155–63. Dewey ME. Coefficients of agreement[J]. Br J Psychiatry. 1983;143:487–89. Santos JG, Brito JO, de Andrade DC, Kaziyama VM, Ferreira KA, Souza I, et al. Translation to Portuguese and validation of the Douleur Neuropathique 4 questionnaire[J]. J Pain. 2010;11(5):484–90. Kapstad H, Rokne B, Stavem K. Psychometric properties of the Brief Pain Inventory among patients with osteoarthritis undergoing total hip replacement surgery[J]. Health Qual Life Outcomes. 2010;8:148. YOUDEN W J. Index for rating diagnostic tests[J]. Cancer. 1950;3(1):32–5. Santos JG, Brito JO, de Andrade DC, Kaziyama VM, Ferreira KA, Souza I, et al. Translation to Portuguese and validation of the Douleur Neuropathique 4 questionnaire[J]. J Pain. 2010;11(5):484–90. Wall PD. Neuropathic pain and injured nerve: central mechanisms[J]. Br Med Bull. 1991;47(3):631–43. Devor M. Neuropathic pain and injured nerve: peripheral mechanisms[J]. Br Med Bull. 1991;47(3):619–30. Freynhagen R, Baron R, Tolle T, Stemmler E, Gockel U, Stevens M, et al. Screening of neuropathic pain components in patients with chronic back pain associated with nerve root compression: a prospective observational pilot study (MIPORT)[J]. Curr Med Res Opin. 2006;22(3):529–37. Hamdan A, Luna JD, Del PE, Galvez R. Diagnostic accuracy of two questionnaires for the detection of neuropathic pain in the Spanish population[J]. Eur J Pain. 2014;18(1):101–09. Wang YF, Yang CC, Ro LS, Tsai YC, Lin KP, Sun WZ, et al. Development and validation of a Taiwan version of the DN4-T questionnaire[J]. J Chin Med Assoc. 2019;82(8):623–27. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1AppendixA.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6881253","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":497168391,"identity":"d8ffe280-9c71-4c57-b6ab-295c0b09b44d","order_by":0,"name":"Xiaofeng Chang","email":"","orcid":"","institution":"Department of Knee Joint Surgery, Honghui Hospital, Xi’an Jiaotong University, No. 555 E.Youyi Rd, Xi'an, 710054, China","correspondingAuthor":false,"prefix":"","firstName":"Xiaofeng","middleName":"","lastName":"Chang","suffix":""},{"id":497168392,"identity":"f7d51c72-333b-4582-92f1-a04b138a630c","order_by":1,"name":"Shuxin Yao","email":"","orcid":"","institution":"Department of Knee Joint Surgery, Honghui Hospital, Xi’an Jiaotong University, No. 555 E.Youyi Rd, Xi'an, 710054, China","correspondingAuthor":false,"prefix":"","firstName":"Shuxin","middleName":"","lastName":"Yao","suffix":""},{"id":497168393,"identity":"948d5a26-a0da-4f6d-baaf-57e692b09c99","order_by":2,"name":"Jie Wei","email":"","orcid":"","institution":"State Key Laboratory of Cancer Biology, Department of Pathology, The First Affiliated Hospital of Air Force Military Medical University, No.127 W. Changle Rd, Xi’an,710032, China","correspondingAuthor":false,"prefix":"","firstName":"Jie","middleName":"","lastName":"Wei","suffix":""},{"id":497168394,"identity":"7d9f7764-b9ed-4492-ac62-e9056e3a3616","order_by":3,"name":"Lei Shang","email":"","orcid":"","institution":"Department of Health Statistics, Faculty of Preventive Medicine, the Air Force Military Medical University, No.169 W. Changle Rd, Xi'an, 710032, China","correspondingAuthor":false,"prefix":"","firstName":"Lei","middleName":"","lastName":"Shang","suffix":""},{"id":497168395,"identity":"e479300c-bf3a-4bc0-99e8-0e08eeb168b7","order_by":4,"name":"Chao Xu","email":"","orcid":"","institution":"Department of Knee Joint Surgery, Honghui Hospital, Xi’an Jiaotong University, No. 555 E.Youyi Rd, Xi'an, 710054, China","correspondingAuthor":false,"prefix":"","firstName":"Chao","middleName":"","lastName":"Xu","suffix":""},{"id":497168396,"identity":"b3bd6d39-c9df-458a-8c98-0f4fbfc8ab0b","order_by":5,"name":"Jianbing Ma","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIie3PMQrCMBSA4RcC7RLbNd7iQaFWLL1LKWRSERwdFFw9gMcoCIpbMaiD4izoJri4ZHRwMFXntm6C+SEkw/tIAmAy/WKZXhwBkOqDwjD6jpBpTyTVSJ5WQJlakVGZcE67WAW9qNuwa/IWYkbBluu0iNQPnRnnmPSbY0e02nh2gAlxLCK4r6Wa0DiVzPfaeKXAmV9GZneOwzcJUJJRBTLXt8iceBeoQuqaBBy38XLMfDJBkVhlf3H0w078MYgX7t5T90cYubbcFJI8yt+79dqtsvE8oj5UVZk2mUym/+sJJXFJGxN2Kn8AAAAASUVORK5CYII=","orcid":"","institution":"Department of Knee Joint Surgery, Honghui Hospital, Xi’an Jiaotong University, No. 555 E.Youyi Rd, Xi'an, 710054, China","correspondingAuthor":true,"prefix":"","firstName":"Jianbing","middleName":"","lastName":"Ma","suffix":""}],"badges":[],"createdAt":"2025-06-12 14:23:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6881253/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6881253/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89188145,"identity":"a81212ab-5ab9-4645-8d87-21054e2e5f89","added_by":"auto","created_at":"2025-08-16 07:32:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1141094,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6881253/v1/4c02cae7-5fbc-4a06-828c-713ca0139a41.pdf"},{"id":88586014,"identity":"e06c91ae-c9a8-44db-94a2-df7474a22655","added_by":"auto","created_at":"2025-08-08 04:18:46","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":21884,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1AppendixA.docx","url":"https://assets-eu.researchsquare.com/files/rs-6881253/v1/dcaeb1f63707eb13e92b22e1.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cross-Cultural Adaptation and Psychometric Validation of the Chinese Version of the Douleur Neuropathique 4 Questionnaire in Patients with Knee Osteoarthritis","fulltext":[{"header":"Introduction","content":"\u003cp\u003eKnee osteoarthritis (KOA) is the most prevalent degenerative joint disease among the elderly, characterized by joint pain, stiffness, and functional impairment, which significantly compromises quality of life\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Traditionally, KOA pain has been attributed to mechanical loading and joint inflammation, and therefore classified as nociceptive pain \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. However, accumulating evidence indicates that a subset of KOA patients exhibit neuropathic pain (NeP) features\u0026mdash;such as burning sensations, electric shock\u0026ndash;like pain, paresthesia, and mechanical allodynia\u0026mdash;suggesting involvement of peripheral or central nervous system alterations\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Neuropathic pain is often refractory to conventional therapies\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e, and failure to recognize its presence preoperatively may increase the risk of persistent postoperative pain and delay rehabilitation\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eEarly identification of neuropathic pain components is therefore crucial for personalized pain management and surgical planning in KOA\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Among the screening instruments developed for neuropathic pain, the DN4\u0026mdash;developed by the French Neuropathic Pain Group\u0026mdash;has gained widespread use due to its brevity, ease of administration, and diagnostic accuracy. The DN4 comprises seven symptom-based items and three clinical examination items, and has demonstrated a sensitivity of 83% and specificity up to 90% for detecting neuropathic pain\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Since its introduction, the DN4 has been translated into and validated in multiple languages, including Korean, Japanese, Spanish, Persian, Arabic, Greek, and Dutch\u003csup\u003e[\u003cspan additionalcitationids=\"CR12 CR13 CR14 CR15 CR16\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, and has shown robust psychometric properties in conditions such as diabetic polyneuropathy, post-herpetic neuralgia, and spinal cord injury\u0026ndash;related pain\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eDespite its extensive international application, there is currently no validated Chinese version of the DN4 tailored for KOA populations. Given the potential impact of linguistic structures and cultural nuances\u0026mdash;particularly in symptom description and patient\u0026ndash;clinician communication\u0026mdash;direct adoption of a foreign-language version may undermine measurement accuracy and compromise clinical assessment and intervention decisions. Consequently, cross-cultural adaptation of the DN4 into Chinese for KOA patients (DN4-CV) is essential to ensure reliable identification of neuropathic pain components in this cohort.\u003c/p\u003e\u003cp\u003e This study therefore aims to bridge this gap by cross-culturally adapting and validating the DN4 questionnaire according to the internationally recognized guidelines of Beaton et al.\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e, and by evaluating its reliability, validity, and discriminative capability in a cohort of Chinese KOA patients. Through this work, we intend to provide a scientifically robust and clinically practical tool for screening neuropathic pain in KOA, ultimately facilitating early detection and individualized pain management.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eTranslation and cross-cultural adaptation\u003c/h2\u003e\u003cp\u003eThis study adhered to established guidelines for translation and cross-cultural adaptation, comprising five consecutive steps\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. First, two bilingual native Chinese speakers fluent in English independently translated the original English version of the DN4 questionnaire\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e into Simplified Chinese. One translator was a pain-management specialist familiar with neuropathic pain terminology, and the other was a professional translator without a medical background, thereby ensuring both clinical accuracy and linguistic fluency. The two translations were then compared and reconciled to produce a preliminary consensus version of the Chinese DN4 (DN4-CV). Then, a multidisciplinary expert panel (including the translators, pain clinicians, a linguist, and a methodologist) convened to resolve cultural and contextual discrepancies and to refine the phrasing. Following discussion, the panel drafted the first version of the DN4-CV. During Step three, two additional bilingual translators with medical expertise, blinded to the original DN4, independently back‐translated this draft into English. The back‐translations were reviewed and synthesized, then compared with the source version by the expert committee to confirm conceptual equivalence. Minor revisions were made to enhance semantic accuracy and cultural relevance, yielding the second version of the DN4-CV. Next, the research team held a second expert meeting to review all revisions and ensure consistency across items. This step emphasized the preservation of equivalence in content, intent, and clinical interpretation between the Chinese and English versions; upon conclusion, the final DN4-CV was produced. Finally, the provisional DN4-CV was pilot‐tested in 50 patients diagnosed with knee osteoarthritis. Cognitive debriefing interviews assessed participants\u0026rsquo; comprehension, interpretation, and perceived relevance of each item. Based on patient feedback, minor wording adjustments were made to improve clarity. The resulting version was finalized for subsequent psychometric validation (see Supplementary File 1: Appendix A).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePatients\u003c/h3\u003e\n\u003cp\u003eBetween July 2024 and May 2025, patients were consecutively recruited from the outpatient clinic of Honghui Hospital, Xi\u0026rsquo;an Jiaotong University. Eligible participants were adults (\u0026ge;\u0026thinsp;18 years) with a clinical diagnosis of knee osteoarthritis and persistent pain lasting longer than three months who were able to comprehend and complete study questionnaires. Patients were excluded if they had severe cognitive impairment or other conditions precluding understanding of the survey instruments, coexisting serious systemic illnesses, recent major knee surgery, or concurrent enrollment in other interventional trials or receipt of active pharmacological or therapeutic interventions.\u003c/p\u003e\n\u003ch3\u003eStudy design\u003c/h3\u003e\n\u003cp\u003eThis prospective observational study was designed to translate and cross-culturally adapt the English-language DN4 into Chinese and to evaluate its reliability and validity. Knee osteoarthritis patients were consecutively recruited from the outpatient clinic of the Affiliated Honghui Hospital of Xi\u0026rsquo;an Jiaotong University. The study was conducted in accordance with the ethical principles of the 1964 Declaration of Helsinki and its later amendments, and received approval from the Honghui Hospital Ethics Committee (Approval No. 202,407,017). Written informed consent was obtained from all participants. To determine the required sample size, we followed the guideline recommending a minimum of ten respondents per questionnaire item\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e, yielding at least 100 subjects. An a priori power analysis was also performed using G*Power version 3.1 (D\u0026uuml;sseldorf, Germany); assuming a medium effect size (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.5), α\u0026thinsp;=\u0026thinsp;0.05, power (1\u0026ndash;β)\u0026thinsp;=\u0026thinsp;0.80, and a 1:1 allocation ratio, the minimum total sample size was calculated as 176 patients. To improve precision and allow for potential dropouts, 335 patients were ultimately enrolled, and a post hoc power analysis confirmed the adequacy of the primary statistical tests.\u003c/p\u003e\n\u003ch3\u003eQuestionnaires\u003c/h3\u003e\n\u003cp\u003eAll participants first completed a demographic questionnaire capturing age, sex, height, weight (for BMI calculation), education level, occupation, and living situation. They then completed the PainDETECT questionnaire (PDQ) and the EQ-5D-5L scale to assess neuropathic pain characteristics and health-related quality of life.\u003c/p\u003e\n\u003ch3\u003eEvaluation of neuropathic pain\u003c/h3\u003e\n\u003cp\u003eClinical diagnosis served as the gold standard: experienced neurologists, pain specialists, and orthopedic surgeons classified each patient\u0026rsquo;s pain as Nep or Np based on medical history, physical examination, electromyography, or imaging studies. All enrolled patients underwent this expert evaluation to confirm their pain category.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eDouleur Neuropathique 4 Questionnaire (DN4)\u003c/h2\u003e\u003cp\u003eThe DN4 was originally developed and validated in French and comprises ten items across four domains: seven items evaluate pain quality, while three clinical examination items assess hypoesthesia to touch and pinprick. Responses are \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no,\u0026rdquo; scored 1 and 0 respectively; the total score is the sum of all items, with a cutoff of \u0026ge;\u0026thinsp;4/10 indicating neuropathic pain\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePainDETECT questionnaire (PDQ)\u003c/h3\u003e\n\u003cp\u003eThe PDQ is an internationally recognized screening tool for neuropathic pain containing four sections: (1) a 0\u0026ndash;10 numerical rating scale (NRS) for pain intensity; (2) four graphic patterns to characterize pain course; (3) a body map for patients to mark pain and radiating pain locations; and (4) seven weighted sensory descriptors (e.g., burning, tingling, numbness) to refine pain characterization. The total score ranges from 0 to 38: \u0026le;12 suggests low probability, \u0026ge;\u0026thinsp;19 high probability of neuropathic pain, and 13\u0026ndash;18 is indeterminate. This study used the validated Chinese version of the PDQ\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eEuroQoL five-dimensions questionnaire (EQ-5D-5L)\u003c/h3\u003e\n\u003cp\u003eThe EQ-5D-5L is a widely used, multidimensional health-related quality of life (HRQoL) instrument in large Chinese populations. It assesses five dimensions\u0026mdash;mobility, self-care, usual activities, pain/discomfort, and anxiety/depression\u0026mdash;each on a five-level scale, providing a comprehensive profile of health status\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eData analyses\u003c/h2\u003e\u003cp\u003eThe Kolmogorov\u0026ndash;Smirnov test was applied to examine the normality of questionnaire score distributions. Continuous variables are reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and categorical variables as frequencies and percentages. Statistical analyses were conducted using SPSS version 27.0 (IBM Corp., New York), with a significance threshold set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eFeasibility assessment\u003c/h2\u003e\u003cp\u003eThe feasibility of the questionnaire was evaluated by documenting any difficulties encountered by respondents during completion.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eReliability\u003c/h2\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003eInternal consistency, inter-rater reliability, and test-retest reliability\u003c/h2\u003e\u003cp\u003eInternal consistency was assessed using Cronbach\u0026rsquo;s α coefficient: first for the total DN4-CV scale, and then recalculated after sequentially removing each item to determine its impact on overall reliability. An α value\u0026thinsp;\u0026ge;\u0026thinsp;0.70 was considered acceptable, 0.80\u0026ndash;0.89 good, and \u0026ge;\u0026thinsp;0.90 excellent. To evaluate test-retest reliability, 60 patients were randomly selected from the 335 enrolled and re-administered the DN4-CV at baseline and again after 7 days\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. Intraclass correlation coefficients (ICC) were calculated using a two-way random effects model, with ICC\u0026thinsp;\u0026ge;\u0026thinsp;0.70 indicating good reproducibility\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. Inter-rater agreement between the DN4 classification (score\u0026thinsp;\u0026ge;\u0026thinsp;4 indicating neuropathic pain) and the clinical \u0026ldquo;gold standard\u0026rdquo; diagnosis was assessed via Cohen\u0026rsquo;s κ coefficient: κ\u0026thinsp;=\u0026thinsp;0.41\u0026ndash;0.60 denoted moderate agreement, 0.61\u0026ndash;0.80 good agreement, and \u0026gt;\u0026thinsp;0.80 excellent agreement\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eValidity\u003c/h2\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003eStructural validity\u003c/h2\u003e\u003cp\u003eGiven that factor structure may vary across populations, exploratory factor analysis (EFA) was performed to assess the structural validity of the DN4-CV. Data suitability was confirmed by a Kaiser\u0026ndash;Meyer\u0026ndash;Olkin (KMO) measure\u0026thinsp;\u0026ge;\u0026thinsp;0.60 and a Bartlett\u0026rsquo;s test of sphericity with P\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Principal component analysis was then conducted, retaining factors with eigenvalues\u0026thinsp;\u0026gt;\u0026thinsp;1 (Kaiser\u0026rsquo;s criterion) and applying Varimax orthogonal rotation to clarify factor loadings. Items with absolute loadings\u0026thinsp;\u0026gt;\u0026thinsp;0.40 were retained to ensure each contributed significantly to its respective factor, yielding an interpretable factor model\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eConstruct validity\u003c/h2\u003e\u003cp\u003eConstruct validity was examined by correlating DN4-CV scores with established measures: the PainDETECT questionnaire (PDQ) and the EQ-5D-5L health index, both of which have demonstrated robust psychometric properties in Chinese populations\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. Pearson\u0026rsquo;s correlation coefficients were interpreted as none or negligible (r\u0026thinsp;=\u0026thinsp;0\u0026ndash;0.20), weak (0.21\u0026ndash;0.40), moderate (0.41\u0026ndash;0.60), strong (0.61\u0026ndash;0.80), and very strong (0.81\u0026ndash;1.00)\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e. We hypothesized a strong positive correlation between DN4-CV and PDQ total scores, reflecting convergent validity for neuropathic pain characteristics, and a moderate inverse correlation with EQ-5D-5L, demonstrating discriminant validity with respect to health-related quality of life.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eROC curve analysis\u003c/h2\u003e\u003cp\u003eReceiver operating characteristic (ROC) curve analysis was conducted to evaluate the discriminative performance of DN4-CV in diagnosing neuropathic pain. Sensitivity and specificity were calculated for each possible cut-off value, and the area under the ROC curve (AUC) quantified overall diagnostic accuracy. The optimal threshold was selected by maximizing Youden\u0026rsquo;s J index (sensitivity\u0026thinsp;+\u0026thinsp;specificity \u0026ndash; 1), thereby providing the best balance of sensitivity and specificity for rapid screening of neuropathic pain in knee osteoarthritis patients\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 335 evaluated patients, 195 (58.2%) were classified as having neuropathic pain (NeP) and 140 (41.8%) as nociceptive pain (NP) based on clinical diagnosis. Demographic characteristics, including sex, age, and sample composition, were comparable between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic data of participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItems\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNeuropathic pain group (N\u0026thinsp;=\u0026thinsp;195)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNociceptive pain group (N\u0026thinsp;=\u0026thinsp;140)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years, mean\u0026thinsp;+\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.131\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex, number(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.651\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWomen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65(33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50(35.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e130(66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90(64.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight (cm, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e162.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e162.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.978\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight (kg, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.498\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBody mass index (mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.358\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducational level, number (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.544\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary school and below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e80(41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65(46.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJunior high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72(36.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48(34.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36(18.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25(17.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUniversity or above (including junior college)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(3.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2(1.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResidence status, number (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.216\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLive alone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14(7.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12(8.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiving with partner\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e118(60.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95(67.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiving with children\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e63(32.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33(23.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployment, number (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.588\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFarming\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e170(87.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e125(89.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRetirement (including no longer farming)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25(12.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15(10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eside, number (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.707\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e106(54.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e79(56.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e89(45.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61(43.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eFeasibility assessment\u003c/h2\u003e\u003cp\u003eNo missing data were observed for the DN4-CV or any other questionnaire items, indicating that the instruments were well-designed and easily understood in a clinical setting. A post hoc power analysis performed with G*Power (α\u0026thinsp;=\u0026thinsp;0.05, Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.5) demonstrated a statistical power of 99.8% for distinguishing NeP from Np patients.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eReliability analysis\u003c/h2\u003e\u003cp\u003eThe DN4-CV exhibited good internal consistency, with an overall Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.805 (recommended threshold\u0026thinsp;\u0026ge;\u0026thinsp;0.70). Item-deleted α values ranged from 0.773 to 0.812, indicating that removal of any single item did not substantially diminish reliability. Corrected item-total correlations varied from 0.263 (Item 8) to 0.613 (Item 7), demonstrating satisfactory discriminative capacity (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Test\u0026ndash;retest reliability was assessed in 60 randomly selected patients re-evaluated after 7 days: the intraclass correlation coefficient (ICC) for average measurements in a two-way mixed effects model was 0.805 (95% CI: 0.772\u0026ndash;0.835), while the test\u0026ndash;retest ICC was 0.973 (95% CI: 0.955\u0026ndash;0.984); Pearson\u0026rsquo;s r between timepoints was 0.947 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), confirming excellent stability and reproducibility. Agreement between DN4-CV classification (score\u0026thinsp;\u0026ge;\u0026thinsp;4) and the clinical \u0026ldquo;gold standard\u0026rdquo; diagnosis was 97.9%, with Cohen\u0026rsquo;s κ\u0026thinsp;=\u0026thinsp;0.957 (SE\u0026thinsp;=\u0026thinsp;0.016; 95% CI: 0.926\u0026ndash;0.988; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCronbach's Alpha to the Items of the Instrument\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItems\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCronbach's Alpha \u0026ndash; Removing the Item\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBurning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.775\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePainful sensation of cold\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.785\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eElectric shocks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.782\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTingling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.776\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePins and needles\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.785\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumbness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.775\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.773\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypoesthesia to touch\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.812\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypoesthesia to prick\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.806\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBrushing\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.805\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCronbach's Alpha \u0026ndash; Total Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.805\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec22\" class=\"Section3\"\u003e\u003ch2\u003eStructural validity\u003c/h2\u003e\u003cp\u003eExploratory factor analysis supported a two-factor structure for the DN4-CV. The Kaiser\u0026ndash;Meyer\u0026ndash;Olkin measure was 0.861 and Bartlett\u0026rsquo;s test was significant (χ\u0026sup2; = 1004.98, df\u0026thinsp;=\u0026thinsp;45, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating data suitability. Two factors with eigenvalues\u0026thinsp;\u0026gt;\u0026thinsp;1 were retained, explaining 56.32% of the total variance (factor 1: 38.44%; factor 2: 17.88%). After Varimax rotation, Items 1\u0026ndash;7 loaded strongly on factor 1 (loadings 0.542\u0026ndash;0.799) and Items 8\u0026ndash;10 on factor 2 (loadings 0.249\u0026ndash;0.673), with overall loadings ranging from 0.249 to 0.799, confirming a clear and interpretable factorial structure (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFactor Loadings for the DN4 Questionnaire Items (Principal Component Analysis)*\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"1\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItems\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFactor 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eFactor 2\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBurning\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.768\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.055\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePainful sensation of cold\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.674\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.052\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eElectric shocks\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.738\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e-0.024\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTingling\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.701\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.178\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePins and needles\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.662\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.072\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumbness\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.739\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.104\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItching\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.776\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.074\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypoesthesia to touch\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.029\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.799\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypoesthesia to prick\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.094\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.793\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBrushing\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.106\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.786\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEigenvalue\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.844\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e1.788\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e% of Variance\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38.44\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e17.88\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCumulative % Variance\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e56.32\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKMO (Sampling Adequacy)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e0.861\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBartlett's Test (Chi-Square)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e1004.978 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"1\" nameend=\"c4\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u0026lowast;Main components with Varimax rotation.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\u003ch2\u003eConstruct validity\u003c/h2\u003e\u003cp\u003eDN4-CV total scores correlated strongly with PDQ total scores (Pearson\u0026rsquo;s r\u0026thinsp;=\u0026thinsp;0.732, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and moderately with EQ-5D-5L index values (r\u0026thinsp;=\u0026thinsp;0.502, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), supporting convergent and discriminant validity. Independent-samples t-tests comparing NeP (n\u0026thinsp;=\u0026thinsp;195) and Np (n\u0026thinsp;=\u0026thinsp;140) groups revealed highly significant differences in DN4 scores (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) with large effect sizes (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;1.25\u0026ndash;4.03; Tables\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDescriptive statistics for DN4 Score, PainDETECT Score and EQ-5D-5L Total Score\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNeuropathic pain group (N\u0026thinsp;=\u0026thinsp;195)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNociceptive pain group (N\u0026thinsp;=\u0026thinsp;140)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDN4 Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePainDETECT Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEQ-5D-5L Total Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData are presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eConvergent and discriminant validity of the DN4 questionnaire in neuropathic pain (NeP) versus nociceptive pain (Np) groups.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eValidity type\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVariable / Comparison\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStatistic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eValue\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eConvergent Validity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDN4 and PDQ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePearson\u0026rsquo;s r (p)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.732\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDN4 and EQ-5D-5L\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePearson\u0026rsquo;s r (p)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.502\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eDiscriminant Validity\u003c/p\u003e\u003cp\u003e(Nep with Np)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDN4 Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean Δ\u0026thinsp;=\u0026thinsp;4.91; d\u0026thinsp;=\u0026thinsp;2.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePDQ Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean Δ\u0026thinsp;=\u0026thinsp;13.6; d\u0026thinsp;=\u0026thinsp;4.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEQ-5D-5L Total Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean Δ\u0026thinsp;=\u0026thinsp;3.34; d\u0026thinsp;=\u0026thinsp;1.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDifferences between patients with neuropathic pain (NeP) and those with nociceptive pain (NP) were compared using independent samples t-tests. Data are presented as follows: \u0026ldquo;Mean Δ\u0026rdquo; denotes the difference in group means NeP minus Np; \u0026ldquo;d\u0026rdquo; denotes Cohen\u0026rsquo;s d effect size (all d\u0026thinsp;\u0026gt;\u0026thinsp;0.8, indicating large effects).\u003c/p\u003e\u003cdiv id=\"Sec24\" class=\"Section3\"\u003e\u003ch2\u003eDiagnostic validity (ROC curve analysis)\u003c/h2\u003e\u003cp\u003eReceiver operating characteristic analysis yielded an area under the curve (AUC) of 0.979 (95% CI: 0.962\u0026ndash;0.996), indicating excellent discriminative accuracy of the DN4-CV. The optimal cutoff score of 3.5 (Youden\u0026rsquo;s J\u0026thinsp;=\u0026thinsp;0.954) provided a sensitivity of 99.0%, specificity of 96.4%, positive predictive value of 97.5%, negative predictive value of 98.5%, and overall accuracy of 97.9% (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDiagnostic performance metrics of the DN4 questionnaire in a sample\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMetric\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eValue\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAccuracy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.979\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSensitivity (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e99.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSpecificity (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e96.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePositive predictive value (PPV) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e97.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNegative predictive value (NPV) (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e98.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCohen\u0026rsquo;s kappa\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.957\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData are presented as proportion or percentage as indicated.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we have, for the first time in Chinese patients with knee osteoarthritis (KOA), completed the cross-cultural adaptation and psychometric validation of the Chinese version of the Douleur Neuropathique 4 questionnaire (DN4-CV), demonstrating its excellent performance for preoperative screening of neuropathic pain.\u003c/p\u003e\u003cp\u003eThe DN4-CV exhibited strong internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.805), which is marginally higher than that reported for the Portuguese (α\u0026thinsp;=\u0026thinsp;0.713)\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e and Spanish (α\u0026thinsp;=\u0026thinsp;0.71) \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e versions, and comparable to the Korean version (α\u0026thinsp;=\u0026thinsp;0.819)\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e, indicating that the core symptoms of neuropathic pain are reliably captured across different cultural contexts. Test\u0026ndash;retest reliability was outstanding (ICC\u0026thinsp;=\u0026thinsp;0.973), mirroring the Portuguese data (ICC\u0026thinsp;=\u0026thinsp;0.969)\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e and confirming excellent reproducibility over a one-week interval (ICC\u0026thinsp;\u0026gt;\u0026thinsp;0.90 is considered very high consistency). Cohen\u0026rsquo;s κ analysis further showed agreement between DN4-CV classification and the clinical \u0026ldquo;gold standard,\u0026rdquo; supporting the scale\u0026rsquo;s structural coherence and repeatability.\u003c/p\u003e\u003cp\u003eExploratory factor analysis (EFA) extracted two principal factors accounting for 56.32% of the total variance. Factor 1(Spontaneous Sensory Symptoms) comprised the descriptors \u0026ldquo;burning,\u0026rdquo; \u0026ldquo;painful cold,\u0026rdquo; \u0026ldquo;electric shocks,\u0026rdquo; \u0026ldquo;tingling,\u0026rdquo; \u0026ldquo;pins and needles,\u0026rdquo; \u0026ldquo;numbness,\u0026rdquo; and \u0026ldquo;itching,\u0026rdquo; reflecting small-fiber hyperexcitability or ectopic discharge commonly seen in small‐fiber dysfunction and peripheral nerve terminal sensitization. Factor 2༈Evoked Hypoesthesia༉ included the clinical examination items \u0026ldquo;hypoesthesia to touch,\u0026rdquo; \u0026ldquo;hypoesthesia to prick,\u0026rdquo; and \u0026ldquo;brushing,\u0026rdquo; representing attenuated nerve conduction combined with central sensitization. By comparison, the original French version yielded nine factors\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e, and the Portuguese version three factors explaining 57.25% of variance (loadings 0.384\u0026ndash;0.645)\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. The broader loading range in our study (0.249\u0026ndash;0.799) further supports the DN4-CV\u0026rsquo;s robust structural validity.\u003c/p\u003e\u003cp\u003eThe DN4-CV demonstrated strong construct validity in our KOA cohort. Its total score correlated highly with the PDQ total score (Pearson\u0026rsquo;s r\u0026thinsp;=\u0026thinsp;0.732, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), confirming convergent validity with an established neuropathic pain measure, and showed a moderate correlation with the EQ-5D-5L index (r\u0026thinsp;=\u0026thinsp;0.502, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), supporting discriminant validity against health-related quality of life. Furthermore, when participants were stratified by the clinical \u0026ldquo;gold standard\u0026rdquo; diagnosis into Nep (n\u0026thinsp;=\u0026thinsp;195) and Np (n\u0026thinsp;=\u0026thinsp;140) groups, independent-samples t-tests revealed highly significant differences in DN4-CV scores (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) with very large effect sizes (Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;1.25\u0026ndash;4.03). These results confirm that the DN4-CV not only aligns closely with other measures of neuropathic pain but also robustly distinguishes between neuropathic and nociceptive pain phenotypes, underscoring its utility as a valid screening tool.\u003c/p\u003e\u003cp\u003eROC curve analysis demonstrated excellent discrimination between neuropathic and nociceptive pain in KOA patients, with an AUC of 0.979 (95% CI: 0.962\u0026ndash;0.996), exceeding the Spanish (AUC 0.85)\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e, Greek (AUC 0.89)\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e, and Dutch (AUC 0.82)\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e versions, and matching the Persian (AUC 0.97)\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e and Arabic (AUC 0.97)\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e versions. This high accuracy may reflect the homogeneity of pain phenotypes in KOA and the use of independent neurologist diagnoses as the \u0026ldquo;gold standard\u0026rdquo; to minimize bias. A cutoff of 3.5 maximized Youden\u0026rsquo;s index (0.954) with sensitivity of 99.0% and specificity of 96.4%.\u003c/p\u003e\u003cp\u003eOriginally, the DN4 demonstrated sensitivity of 82.9% and specificity of 89.9% for neuropathic pain\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e; the Spanish version reported 79.8% and 78%\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e, and the Persian version 90% and 95%\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Our findings are at least equivalent, if not superior. Given the differential response of neuropathic pain to analgesics, early identification of neuropathic components is critical for tailoring chronic pain management\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. Mixed-pain phenotypes share clinical features with pure neuropathic pain\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e, and the DN4 effectively distinguishes between them \u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e. With its brevity and ease of scoring, the DN4-CV is well suited for routine outpatient screening of neuropathic pain\u003csup\u003e[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]\u003c/sup\u003e. For clinical practicality, we recommend rounding to \u0026ge;\u0026thinsp;4, consistent with the Taiwanese\u003csup\u003e[\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/sup\u003e and Korean\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e adaptations, while retaining high sensitivity and specificity. We recommend that patients scoring\u0026thinsp;\u0026ge;\u0026thinsp;4 be targeted for early individualized pain management and postoperative interventions to optimize analgesia and improve patient satisfaction.\u003c/p\u003e\u003cp\u003eThis single-center, cross-sectional design, although conducted at the largest orthopedic center in northwest China, may limit generalizability. As a self-report instrument, the DN4-CV remains susceptible to response bias and variable comprehension. Finally, the \u0026ldquo;gold standard\u0026rdquo; was expert clinical diagnosis without adjunctive objective physiological or imaging biomarkers, leaving diagnostic validity open to further enhancement. Future multicenter, longitudinal studies incorporating objective criteria are warranted to comprehensively evaluate the DN4-CV\u0026rsquo;s reliability, validity, and responsiveness in clinical practice.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results support the cross-cultural validity of the DN4 questionnaire: the DN4-CV demonstrates strong reliability, clear structural validity, and excellent diagnostic accuracy, and can serve as a reliable tool for screening neuropathic pain in clinical settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDN4\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDouleur Neuropathique 4 Questionnaire\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDN4-CV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChinese version of the Douleur Neuropathique 4 Questionnaire\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEFA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eExploratory factor analysis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eEQ-5D-5L\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eEuroQoL five-dimensions questionnaire\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eICC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntraclass correlation coefficient\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eKOA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eKnee osteoarthritis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNeP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNeuropathic pain\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNociceptive pain\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNSAIDs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNonsteroidal anti-inflammatory drugs\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePDQ\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePainDETECT questionnaire\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eROC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eReceiver operating characteristic\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eTKA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eTotal knee arthroplasty\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki.This prospective observational study was approved by the Medical Ethics Committee of Honghui Hospital (Approval No. 202,407,017). Informed consent was obtained from all participants involved in the study.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research was supported by the Key Research and Development Program of Shaanxi Province (2023-YBSF-464), the Cultivation Project for General Projects of Xi\u0026apos;an Health Commission (2024ms10), the 2024 Ministry of Education Humanities and Social Sciences Project (24YJAZH032), the Program for Innovation Team of Shaanxi Province (2023-CX-TD-73).\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eCX and JBM conceived and designed the experiment. XFC,SXY, and JW collected data. XFC,CX, and JBM analyzed and interpreted the data. XFC, SXY and JW wrote the manuscript. LS and JBM modifed the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eAcknowledgments: This research was supported by the Key Research and Development Program of Shaanxi Province (2023-YBSF-464), the Cultivation Project for General Projects of Xi\u0026apos;an Health Commission (2024ms10), the 2024 Ministry of Education Humanities and Social Sciences Project (24YJAZH032), the Program for Innovation Team of Shaanxi Province (2023-CX-TD-73). We thank all the patients and experts who participated in the study and the individuals who helped with preparing the paper.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eAvailability of data and materials As the datasets will be used for future research, the datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eCui A, Li H, Wang D, Zhong J, Chen Y, Lu H. Global, regional prevalence, incidence and risk factors of knee osteoarthritis in population-based studies[J]. EClinicalMedicine, 2020,29\u0026ndash;30:100587.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePrieto-Alhambra D, Judge A, Javaid MK, Cooper C, Diez-Perez A, Arden NK. Incidence and risk factors for clinically diagnosed knee, hip and hand osteoarthritis: influences of age, gender and osteoarthritis affecting other joints[J]. Ann Rheum Dis. 2014;73(9):1659\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFelson DT, Lawrence RC, Dieppe PA, Hirsch R, Helmick CG, Jordan JM, et al. Osteoarthritis: new insights. Part 1: the disease and its risk factors[J]. Ann Intern Med. 2000;133(8):635\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOhtori S, Orita S, Yamashita M, Ishikawa T, Ito T, Shigemura T, et al. Existence of a neuropathic pain component in patients with osteoarthritis of the knee[J]. Yonsei Med J. 2012;53(4):801\u0026ndash;05.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFingleton C, Smart K, Moloney N, Fullen BM, Doody C. Pain sensitization in people with knee osteoarthritis: a systematic review and meta-analysis[J]. Osteoarthritis Cartilage. 2015;23(7):1043\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBannuru RR, Osani MC, Vaysbrot EE, Arden NK, Bennell K, Bierma-Zeinstra S, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis[J]. Osteoarthritis Cartilage. 2019;27(11):1578\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoss P, Benson H, Will R, Wright A. Patients With Knee Osteoarthritis Who Score Highly on the PainDETECT Questionnaire Present With Multimodality Hyperalgesia, Increased Pain, and Impaired Physical Function[J]. Clin J Pain. 2018;34(1):15\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAttal N, Lanteri-Minet M, Laurent B, Fermanian J, Bouhassira D. The specific disease burden of neuropathic pain: results of a French nationwide survey[J]. Pain. 2011;152(12):2836\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAttal N, Lanteri-Minet M, Laurent B, Fermanian J, Bouhassira D. The specific disease burden of neuropathic pain: results of a French nationwide survey[J]. Pain. 2011;152(12):2836\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, et al. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4)[J]. Pain. 2005;114(1\u0026ndash;2):29\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim HJ, Park JH, Bouhassira D, Shin JH, Chang BS, Lee CK, et al. Validation of the Korean Version of the DN4 Diagnostic Questionnaire for Neuropathic Pain in Patients with Lumbar or Lumbar-Radicular Pain[J]. Yonsei Med J. 2016;57(2):449\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMatsuki Y, Sukenaga N, Miyagi K, Tsunetoh T, Mizogami M, Shigemi K, et al. Reliability and validity of the Japanese translation of the DN4 Diagnostic Questionnaire in patients with neuropathic pain[J]. J Anesth. 2018;32(3):403\u0026ndash;08.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePerez C, Galvez R, Huelbes S, Insausti J, Bouhassira D, Diaz S, et al. Validity and reliability of the Spanish version of the DN4 (Douleur Neuropathique 4 questions) questionnaire for differential diagnosis of pain syndromes associated to a neuropathic or somatic component[J]. Health Qual Life Outcomes. 2007;5:66.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMadani SP, Fateh HR, Forogh B, Fereshtehnejad SM, Ahadi T, Ghaboussi P, et al. Validity and reliability of the persian (Farsi) version of the DN4 (Douleur Neuropathique 4 Questions) questionnaire for differential diagnosis of neuropathic from non-neuropathic pains[J]. Pain Pract. 2014;14(5):427\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHarifi G, Ouilki I, El BI, Ouazar MA, Belkhou A, Younsi R, et al. Validity and reliability of the Arabic adapted version of the DN4 questionnaire (Douleur Neuropathique 4 Questions) for differential diagnosis of pain syndromes with a neuropathic or somatic component[J]. Pain Pract. 2011;11(2):139\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSykioti P, Zis P, Vadalouca A, Siafaka I, Argyra E, Bouhassira D, et al. Validation of the Greek Version of the DN4 Diagnostic Questionnaire for Neuropathic Pain[J]. Pain Pract. 2015;15(7):627\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evan Seventer R, Vos C, Giezeman M, Meerding WJ, Arnould B, Regnault A, et al. Validation of the Dutch version of the DN4 diagnostic questionnaire for neuropathic pain[J]. Pain Pract. 2013;13(5):390\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVan Seventer R, Vos C, Meerding W, Mear I, Le Gal M, Bouhassira D, et al. Linguistic validation of the DN4 for use in international studies[J]. Eur J Pain. 2010;14(1):58\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpallone V, Morganti R, D'Amato C, Greco C, Cacciotti L, Marfia GA. Validation of DN4 as a screening tool for neuropathic pain in painful diabetic polyneuropathy[J]. Diabet Med. 2012;29(5):578\u0026ndash;85.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBeaton DE, Bombardier C, Guillemin F, Ferraz MB. Guidelines for the process of cross-cultural adaptation of self-report measures[J]. Spine (Phila Pa 1976). 2000;25(24):3186\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVan Seventer R, Vos C, Meerding W, Mear I, Le Gal M, Bouhassira D, et al. Linguistic validation of the DN4 for use in international studies[J]. Eur J Pain. 2010;14(1):58\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTerwee CB, Bot SD, de Boer MR, van der Windt DA, Knol DL, Dekker J, et al. Quality criteria were proposed for measurement properties of health status questionnaires[J]. J Clin Epidemiol. 2007;60(1):34\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChang X, Yao S, Wei J, Shang L, Xu C, Ma J. Psychometric Characteristics of the PainDETECT Questionnaire in Patients Undergoing Total Knee Arthroplasty for Osteoarthritis[J]. J Arthroplasty, 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXie S, Wang D, Wu J, Liu C, Jiang W. Comparison of the measurement properties of SF-6Dv2 and EQ-5D-5L in a Chinese population health survey[J]. Health Qual Life Outcomes. 2022;20(1):96.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKoo TK, Li MY. A Guideline of Selecting and Reporting Intraclass Correlation Coefficients for Reliability Research[J]. J Chiropr Med. 2016;15(2):155\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDewey ME. Coefficients of agreement[J]. Br J Psychiatry. 1983;143:487\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSantos JG, Brito JO, de Andrade DC, Kaziyama VM, Ferreira KA, Souza I, et al. Translation to Portuguese and validation of the Douleur Neuropathique 4 questionnaire[J]. J Pain. 2010;11(5):484\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKapstad H, Rokne B, Stavem K. Psychometric properties of the Brief Pain Inventory among patients with osteoarthritis undergoing total hip replacement surgery[J]. Health Qual Life Outcomes. 2010;8:148.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYOUDEN W J. Index for rating diagnostic tests[J]. Cancer. 1950;3(1):32\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSantos JG, Brito JO, de Andrade DC, Kaziyama VM, Ferreira KA, Souza I, et al. Translation to Portuguese and validation of the Douleur Neuropathique 4 questionnaire[J]. J Pain. 2010;11(5):484\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWall PD. Neuropathic pain and injured nerve: central mechanisms[J]. Br Med Bull. 1991;47(3):631\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDevor M. Neuropathic pain and injured nerve: peripheral mechanisms[J]. Br Med Bull. 1991;47(3):619\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFreynhagen R, Baron R, Tolle T, Stemmler E, Gockel U, Stevens M, et al. Screening of neuropathic pain components in patients with chronic back pain associated with nerve root compression: a prospective observational pilot study (MIPORT)[J]. Curr Med Res Opin. 2006;22(3):529\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHamdan A, Luna JD, Del PE, Galvez R. Diagnostic accuracy of two questionnaires for the detection of neuropathic pain in the Spanish population[J]. Eur J Pain. 2014;18(1):101\u0026ndash;09.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang YF, Yang CC, Ro LS, Tsai YC, Lin KP, Sun WZ, et al. Development and validation of a Taiwan version of the DN4-T questionnaire[J]. J Chin Med Assoc. 2019;82(8):623\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Knee osteoarthritis, Neuropathic pain, DN4 questionnaire, Cross-cultural adaptation, Psychometric validation","lastPublishedDoi":"10.21203/rs.3.rs-6881253/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6881253/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eKnee osteoarthritis (KOA) patients frequently continue to experience persistent pain and functional limitations following total knee arthroplasty (TKA), posing substantial challenges for postoperative pain management. Accurate preoperative characterization of pain profiles is therefore essential for devising individualized treatment strategies. The Douleur Neuropathique 4 Questionnaire (DN4) is a concise, validated instrument for detecting neuropathic pain components and has demonstrated robust reliability and validity across diverse cultural settings. However, to date no culturally adapted Chinese version is available. This study aimed to translate and culturally adapt the DN4 into Chinese (DN4-CV) and to evaluate its psychometric properties in a cohort of Chinese KOA patients undergoing TKA.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e Following established cross-cultural adaptation guidelines, the original DN4 was forward- and back-translated by bilingual experts, harmonized by a multidisciplinary panel, and piloted in 50 KOA patients. The finalized Chinese DN4 (DN4-CV) was administered to 335 KOA outpatients. Psychometric properties were assessed via internal consistency (Cronbach\u0026rsquo;s α), test\u0026ndash;retest reliability (intraclass correlation coefficient, ICC), exploratory factor analysis (EFA) for structural validity, and receiver operating characteristic (ROC) analysis. The optimal cutoff score was determined by maximizing Youden\u0026rsquo;s index.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe DN4-CV demonstrated good internal consistency (α\u0026thinsp;=\u0026thinsp;0.805) and excellent test\u0026ndash;retest reliability (ICC\u0026thinsp;=\u0026thinsp;0.973). EFA identified two factors accounting for 56.32% of total variance. ROC analysis yielded an area under the curve of 0.979 (95% CI: 0.962\u0026ndash;0.996). Using a cutoff score\u0026thinsp;\u0026ge;\u0026thinsp;4, sensitivity was 99.0%, specificity 96.4%, positive predictive value 97.5%, negative predictive value 98.5%, and overall accuracy 97.9%.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe DN4-CV is a reliable, valid, and highly accurate tool for screening neuropathic pain in KOA patients, supporting its clinical utility for early identification and individualized pain management.\u003c/p\u003e","manuscriptTitle":"Cross-Cultural Adaptation and Psychometric Validation of the Chinese Version of the Douleur Neuropathique 4 Questionnaire in Patients with Knee Osteoarthritis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-08 04:18:42","doi":"10.21203/rs.3.rs-6881253/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a6378ed3-ae4f-4285-a54b-77c9a9c73fee","owner":[],"postedDate":"August 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-16T07:23:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-08 04:18:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6881253","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6881253","identity":"rs-6881253","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}