Response to the letter to the editor: “Methodological considerations in the evaluation of pain and central sensitization in lipedema”

We sincerely thank the authors for their careful evaluation of our study entitled “A multidimensional evaluation of pain in lipedema” ¹ and for their valuable comments. We are pleased that our work has generated academic interest and discussion.

The primary aim of this study was to examine the relationship between pain parameters; therefore, no control group was created. An interpretation was made based on the cut-off value for central sensitization; the primary goal was not to prove the presence of central sensitization, but since such a finding emerged based on the cut-off value, we wanted to share it in our study. Future studies comparing central sensitization with a control group could contribute to the literature, as it can occur in chronic painful conditions.

Pain is inherently a subjective experience and cannot be fully evaluated in all its dimensions using objective methods alone. Therefore, questionnaire-based and patient-reported outcome measures remain important and widely accepted tools in pain assessment. ² Questionnaire-based assessments such as the Central Sensitization Inventory (CSI) have been widely used and validated for the assessment of pain hypersensitivity and symptoms related to central sensitization. ³ In addition, the use of a verbal rating scale was considered a feasible method for evaluating hypersensitivity in the present study. Nonetheless, although substantial progress has been achieved in pain assessment methodologies, certain aspects of chronic pain evaluation still require further methodological refinement. ⁴ We agree that objective assessment methods for hypersensitivity and central sensitization may provide additional value in the evaluation of pain mechanisms, thereby contributing further to the literature. Furthermore, our limitations include the fact that pain is a subjective perception, and it is acknowledged that pain cannot be evaluated in all its dimensions; in fact, it is assessed, in part, through questionnaire-based methods. In addition, the lack of objective sensory assessment methods, such as pain pressure threshold measurements, was also stated as a limitation of the present study.

Measurements such as waist-to-hip circumference were not included in the study. Although these parameters could have provided additional information, lipedema-specific clinical criteria were primarily used to differentiate lipedema from obesity. The differentiation between lipedema and obesity is well established in the literature based on characteristic clinical criteria. ⁵ Patients with a confirmed diagnosis of lipedema were included in the study. Clinical criteria were applied, and patients were further assessed according to lipedema type and stage, as described in the manuscript. We appreciate the reviewer’s comment regarding potential confounding factors. In our study, 8.2% of the participants had a diagnosis of chronic venous disease. Given this relatively low proportion, and considering that lipedema was the primary complaint while venous disease was generally at an early stage, its potential impact on the overall pain-related outcomes is considered limited.

We thank the authors for their constructive comments and for highlighting the importance of the multidimensional nature of pain in lipedema. We agree that future studies incorporating control groups, objective sensory testing methods, and more detailed evaluation of potential confounding factors will further advance the understanding of pain mechanisms in lipedema.