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Assessment of Pain Beliefs, Coping, and Function
SUMMARY
Individual differences in the experience and impact of pain necessitate the inclusion of cognitive, affective, and functional measures in the assessment of pain, particularly persistent pain. A rich and diverse literature documents the role that pain beliefs and attitudes and pain-coping strategies have on outcomes, including pain severity and the impact of pain on function. This chapter reviews the measures that are commonly used in both research and clinical settings, with a focus on measures that are useful for patients with many different types of painful conditions. Condition-specific tools are available (e.g., the Western Ontario and McMaster Universities Osteoarthritis Index for assessing knee pain–related function; ) and recommended by consensus panels (e.g., ), and these measures are not included in this discussion. Measures of pain beliefs and attitudes, specific dimensions of pain coping, and measures of function are reviewed. Measures of function are divided into measures of pain-related function, psychosocial function, health-related quality of life, and cost outcomes. Pain-related function includes both self-report of the impact of pain on various dimensions of daily life and measurement of pain behavior. Psychosocial function includes assessment of mood and sleep. The section on health-related quality of life includes a brief discussion of some of the more commonly used measures of this construct and is followed by a brief discussion of some methods being applied to evaluate health care utilization, work productivity, and cost outcomes of treatment. Both researchers and clinicians should strive to include measurement of all three domains—pain beliefs, coping, and function—whenever feasible.
Introduction
People display and describe pain in many different ways, from stoical minimization to neurotic exaggeration. Although exceptions do occur, pain, particularly chronic pain, alters daily life, often changing how the person spends his or her time. As pain continues, the impact of the patient’s pain extends to family, social, and work interactions, often challenging the sufferer’s sense of self and personal worth. Even with acute pain—the pain of childbirth or pain following surgery—the meaning of the pain and the emotional dimension of pain influence the description and expression of the pain, as well as what treatments the patient is willing to pursue. Given the prevalence of pain, the chronicity of many painful conditions, and the aging population, pain clinicians and researchers alike need to pay close attention to these other responses to pain—emotional, cognitive, and social responses—in addition to the pathophysiology of the condition underlying the persistent pain. Simplistic interpretations of behavior in the clinical setting can lead to errors in assessment and treatment planning ( ). Although an extensive literature demonstrates the role of these factors in predicting persistent disabling low back pain ( ), more and more evidence indicates that these psychosocial factors predict persistent postoperative pain ( ), as well as response to pain treatments ( ). Unfortunately, assessment of the psychosocial factors discussed in this chapter is often relegated to the last resort after organic approaches and treatments have been exhausted. Ideally, assessment of at least some of the domains addressed in this chapter should be standard in all pain settings, including basic research studies involving human subjects, because the impact of these factors on pain and function is consistent and compelling and continues to elucidate individual differences in the experience of pain and its effect on daily living (see Chapter 21, Chapter 22, Chapter 23 for assessment of pain in different age groups).
Pain Beliefs and Attitudes
Pain beliefs—how we and our patients understand pain and its causes and treatments; the meaning of pain to the patient, family, employer, and treatment team; and our attitudes toward disability and the social and interpersonal effects of pain—can be powerful determinants of a person’s response to pain and the development of pain-related disability. The breadth of concepts and measures currently available to assess pain beliefs and attitudes attests to the value of these constructs in extending our understanding of pain. The range includes patients’ concerns about reporting pain and using pain medications ( ) to acceptance of pain ( ). These beliefs and attitudes affect the experience of both acute and chronic pain and may increase the risk that acute pain becomes chronic. Though activated by the experience of pain, these beliefs are seen across cultures, are influential during childhood, and are not simply artifacts of chronicity or disability. provide an excellent, detailed discussion of the range of pain beliefs examined in chronic pain, particularly measures of beliefs that are pain specific rather than general personality dimensions. The select group of measures presented here has been chosen because of their common use in both clinical and research settings.
General Measures of Pain Beliefs and Attitudes
The Survey of Pain Attitudes (SOPA; ) measures attitudes and beliefs that pain can be controlled, that emotions influence pain, that pain signals harm, and that a medical cure will be found, as well as attitudes and beliefs about using pain medications, about disability, and about needing care and attention. The original 57-item scale has been shortened to 35 items and shows excellent psychometric properties that are comparable to scores generated by the original scale, with the exception of the harm subscale ( ). Validation of many of the SOPA subscales has accumulated over a number of studies. Cancer patients reporting strong beliefs about using pain medications and low perceptions of controlling pain report greater adherence in using pain medications ( ). Following multidisciplinary treatment, beliefs that pain is disabling and harmful decrease and perceptions of pain as controllable increase ( ), although these gains are not sustained in about 30% of patients ( ). To facilitate broad use of the SOPA measure in the context of a comprehensive assessment, reliable and valid one- and two-item subscales have been identified ( ).
Specific Measures of Pain Beliefs and Attitudes
Self-Efficacy
Self-efficacy, or confidence that one can cope with pain and its impact on daily life, is one of the most consistent predictors of pain-related outcomes ( ), although it is not consistently related to pain intensity ( ). Individuals with high self-efficacy report lower levels of disability and depression, and a recent review found that high self-efficacy predicted which patients would benefit most from self-management interventions ( ). Measurement of self-efficacy generally includes multiple dimensions, with most scales including specific types of behavior, as well as broader concepts such as “coping with pain.” Since most measures do not instruct the patient to consider the level of pain when rating confidence in performing a task, developed the Pain Self-Efficacy Questionnaire, which includes confidence ratings of general activities (such as “socialize with my friends or family members as often as I used to do despite the pain”). Other commonly used scales include the Chronic Pain Self Efficacy Scale ( ) and the Arthritis Self Efficacy Scale ( ). The Arthritis Self Efficacy Scale has been the most widely studied and shows consistent relationships with pain, fatigue, and physical disability in patients with arthritis ( ).
Acceptance
In the past decade, acceptance of pain ( ) has received increasing attention and empirical support as a psychological process associated with better outcomes in patients with chronic pain ( ), including less avoidance and disability ( ). The strength of these associations has contributed to the reshaping of cognitive–behavioral therapies for pain to incorporate mindfulness, acceptance, values, and committed action with the goal of enhancing psychological flexibility ( ), although the specific role of acceptance as opposed to increased perception of control over pain remains unclear in the psychological treatment of chronic pain ( ). The original Chronic Pain Acceptance Questionnaire ( ) was later revised to include 20 items that include Measurement of Pain Willingness and Activity Engagement ( ).
Fear Avoidance
Because of the aversive nature of pain, conditioning of fear and then avoidance of certain events or activities, particularly those that evoke pain, can occur when pain becomes chronic. Distinct from the dysphoria or negative affectivity often seen with chronic pain, pain-related anxiety and fear contribute uniquely to adaptation. and later revised ( ) a cognitive–behavioral model that depicts a chain of events that can transpire in response to painful experiences brought on by a back injury ( Fig. 24-1 ). Particularly in people who experience high levels of negative affectivity and perceive pain as threatening, pain can activate catastrophizing (a complex cognitive–emotional response to pain—see later), which then activates pain-related anxiety and fear of continued pain and leads to avoidance and attempts to escape from the pain and anxiety. People in this cycle may become less physically active and engaged in their daily life, show diminished muscle strength and restricted movements, and ultimately report functional limitations and depression ( ). When pain does not activate catastrophizing and the individual confronts the pain, recovery is more likely to occur. Fear-avoidance beliefs capture the dimension that pain is to be avoided rather than confronted. A rich literature demonstrates the disabling nature of these beliefs, largely in individuals with low back pain, and the relationship with disability is typically stronger than that with pain intensity. These beliefs may have broad applicability to many types of chronic musculoskeletal pain conditions, including fibromyalgia and osteoarthritis ( ), as well as long-term postoperative outcomes ( ). Fear-avoidance beliefs are most commonly measured with the Tampa Scale of Kinesiophobia (unpublished report by ) or the Fear-Avoidance Beliefs Questionnaire ( ), which is specific to back pain. Items for the 17-item Tampa Scale of Kinesiophobia are provided in an appendix to Vlaeyan and colleagues’ paper validating the Dutch translation (1995), and recent work has validated a shorter (11 item) scale with two primary factors: somatic focus and activity avoidance ( ).
Pain Coping
How individuals cope with chronic pain is a consistent predictor of various dimensions of the experience of pain, including pain severity, disability and physical function, and psychological adaptation ( ), although evidence supporting the adaptive value of any individual coping strategy is weak ( ). The conceptual issues in measuring coping and determining the maladaptive or adaptive nature of any individual or composite measure of coping are complex ( ). Consider the possibility that a superficially maladaptive coping strategy may serve a subtle but valuable role in the individual’s life. For example, rest may be unproductive and even harmful and can result in deconditioning and physical incapacity when used to cope with months or years of low back pain. However, rest may play an important, adaptive role for that individual in that it can enhance a sense of control over the pain by providing pain relief and predictability or providing quiet time away from the stress of a disrupted family life. Any pain-coping strategy may be adaptive in one domain and maladaptive in another ( ).
General Measures of Pain Coping
Current technologies for measuring pain-coping strategies have strengths and weaknesses. The most frequently used measures of pain-coping strategies in the chronic pain literature are the Coping Strategies Questionnaire (CSQ; ), which focuses primarily on cognitive coping strategies; the Vanderbilt Pain Management Inventory ( ), which measures active and passive pain-coping strategies; and the Chronic Pain Coping Inventory (CPCI; ), which provides a measure of specific behavioral pain-coping strategies—rest, relaxation, exercise and stretching, and seeking social support—to complement the primarily cognitive focus of the CSQ. A 42-item scale has been developed to facilitate repeated assessments ( ). One- and two-item subscales for both the CSQ and the CPCI have been published ( ).
In recent discussions, theoreticians have maligned the use of summary checklists to assess this complex construct, which is thought to change rapidly over time as the individual’s life transpires. Daily diaries ( ) illuminate the complexities of coping with pain and allow detailed examination of the impact of a coping attempt over a period of hours or days. Revelations that paper diaries are frequently not completed in a timely fashion ( ) support the value of extending modern electronic monitoring devices to the assessment of coping ( ). These technologies are extremely valuable to the researcher and may be positively perceived by busy clinicians, although they are not consistently integrated into treatment decision making ( ). Even though diaries are useful in many ways, most of our knowledge of how individuals cope with pain, particularly chronic pain, derives from checklist methods that despite their limitations, have provided a wealth of information about coping with pain.
Specific Dimensions of Pain Coping
Catastrophizing
Catastrophizing, a negative emotional–cognitive–attitudinal response to pain, is a pain-coping strategy that has received a great deal of attention in the psychosocial pain literature (e.g., ), primarily because of its consistently strong relationship with poorer functioning. Catastrophizing correlates with pain, pain-related interference and disability, and depressive symptoms across studies, laboratories, and patient groups ( ). Although most data on catastrophizing are cross-sectional, longitudinal analyses support its role in determining the level of pain, pain-related function, and depressive symptoms months later ( ), and an isolated study suggests a beneficial effect of catastrophizing on pain-related function and depressive symptoms in the months immediately following an amputation ( ). Fairly consistently, catastrophizing is reduced following multidisciplinary or behavioral treatment, and longitudinal analyses suggest that reductions in catastrophizing occur before improvements in other outcomes ( ).
Two measures of catastrophizing are most widely used: the catastrophizing subscale of the CSQ ( ) and the Pain Catastrophizing Scale ( ). The CSQ consists of 50 items that assess how the individual copes with pain, including a number of primary scales (coping self-statements, diverting attention, ignoring sensations, reinterpreting sensations, praying and hoping, increasing activity, and catastrophizing). Although composite coping scores are often used, individual scales provide more information and are generally recommended ( ). The catastrophizing subscale of the CSQ includes six items (e.g., “I worry all the time about whether the pain will end”) measuring the general construct of helplessness. Multiple factor analyses of the CSQ support the validity of the catastrophizing subscale in particular (e.g., ). The 13-item Pain Catastrophizing Scale ( Fig. 24-2 ) includes a rumination subscale (e.g., “I can’t seem to keep it out of my mind”) and a magnification subscale (e.g., “I become afraid that the pain will get worse”), in addition to the original CSQ subscale measuring helplessness. This factor structure has been confirmed in later analyses ( ), although psychometric analysis of a racially diverse group of workers’ compensation claimants suggested a two-factor structure in the African American group ( ).
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