Predictive utility of the CSQ in low back pain: individual vs. composite measures

Confirmatory Factor Analysis, Reliability, and Validity of the Persian Version of the Coping Strategies Questionnaire for Iranian People With Nonspecific Chronic Neck Pain

OBJECTIVE

The purpose of this study was to assess the reliability and construct validity of, and perform confirmatory factor analysis of, the Persian version of the Coping Strategies Questionnaire (CSQ) for Iranian people with nonspecific chronic neck pain.

METHODS

We performed psychometric testing of the Persian version of the Coping Strategies Questionnaire. Participants were 123 native Persian speakers with chronic neck pain lasting at least 3 months. They were between 18 and 55 years old. The CSQ was administered by self-report. After 5 to 7 days, 94 participants completed the questionnaire in the retest session. Confirmatory factor analysis was done to assess the model fit (χ² test, comparative fit index, and root-mean-square error of approximation) of the 7-factor solution of the Persian version of the CSQ. The Cronbach α was used for internal consistency; intraclass correlation coefficient, standard error of measurement, and minimal detectable change for reliability; and nonparametric tests of group differences and correlations for construct validity. To assess the construct validity, we examined the ability of the CSQ to discriminate people based on sex, level of education, and physical activity. Correlations with the Short Form Health Survey (SF-12), Tampa Scale for Kinesiophobia, visual analog scale, Fear-Avoidance Beliefs Questionnaire, Pain Catastrophizing Scale, and Neck Disability Index were also determined to test the validity.

RESULTS

Confirmatory factor analysis measures-χ² test, comparative fit index, and root-mean-square error of approximation-were 1.72, 0.76, and 0.07, respectively. Internal consistency was excellent (0.85). All intraclass correlation coefficients were above the acceptable level of 0.70, with the highest reliability obtained for the Praying subscale in both test and retest sessions. The standard error of measurement for the CSQ total score was 2.26, and the minimal detectable change was 6.25. The Cronbach α for the total score and for the subscales ranged from 0.75 to 0.93. Scores of the subscales of the CSQ and other questionnaires showed low correlation except for the physical component of the SF-12. The Catastrophizing subscale had a positive correlation with the Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia, Fear-Avoidance Beliefs Questionnaire, and Neck Disability Index, and a negative correlation with the SF-12.

CONCLUSION

The CSQ has acceptable and good measurement properties to assess coping strategies in Iranian people with nonspecific chronic neck pain. It is a reliable measure, though, for validity only The Catastrophizing subscale showed significant correlation with other scales, but the findings should be interpreted with caution because of the limitations of the study.

An experimental investigation of the relationships among race, prayer, and pain

Background and aims Compared to White individuals, Black individuals demonstrate a lower pain tolerance. Research suggests that differences in pain coping strategies, such as prayer, may mediate this race difference. However, previous research has been cross-sectional and has not determined whether prayer in and of itself or rather the passive nature of prayer is driving the effects on pain tolerance. The aim of this study was to clarify the relationships among race, prayer (both active and passive), and pain tolerance. Methods We randomly assigned 208 pain-free participants (47% Black, 53% White) to one of three groups: active prayer ("God, help me endure the pain"), passive prayer ("God, take the pain away"), or no prayer ("The sky is blue"). Participants first completed a series of questionnaires including the Duke University Religion Index, the Coping Strategies Questionnaire-Revised (CSQ-R), and the Pain Catastrophizing Scale. Participants were then instructed to repeat a specified prayer or distractor coping statement while undergoing a cold pressor task. Cold pain tolerance was measured by the number of seconds that had elapsed while the participant's hand remained in the cold water bath (maximum 180 s). Results Results of independent samples t-tests indicated that Black participants scored higher on the CSQ-R prayer/hoping subscale. However, there were no race differences among other coping strategies, religiosity, or catastrophizing. Results of a 2 (Race: White vs. Black)×3 (Prayer: active vs. passive vs. no prayer) ANCOVA controlling for a general tendency to pray and catastrophizing in response to prayer indicated a main effect of prayer that approached significance (p=0.06). Pairwise comparisons indicated that those in the active prayer condition demonstrated greater pain tolerance than those in the passive (p=0.06) and no prayer (p=0.03) conditions. Those in the passive and no prayer distractor conditions did not significantly differ (p=0.70). There was also a trending main effect of race [p=0.08], with White participants demonstrating greater pain tolerance than Black participants. Conclusions Taken together, these results indicate that Black participants demonstrated a lower pain tolerance than White participants, and those in the active prayer condition demonstrated greater tolerance than those in the passive and no prayer conditions. Furthermore, Black participants in the passive prayer group demonstrated the lowest pain tolerance, while White participants in the active prayer group exhibited the greatest tolerance. Results of this study suggest that passive prayer, like other passive coping strategies, may be related to lower pain tolerance and thus poorer pain outcomes, perhaps especially for Black individuals. On the other hand, results suggest active prayer is associated with greater pain tolerance, especially for White individuals. Implications These results suggest that understanding the influence of prayer on pain may require differentiation between active versus passive prayer strategies. Like other active coping strategies for pain, active prayer may facilitate self-management of pain and thus enhance pain outcomes independent of race. Psychosocial interventions may help religiously-oriented individuals, regardless of race, cultivate a more active style of prayer to improve their quality of life.

Evaluating psychosocial contributions to chronic pain outcomes

The biopsychosocial model of pain dominates the scientific community's understanding of chronic pain. Indeed, the biopsychosocial approach describes pain and disability as a multidimensional, dynamic integration among physiological, psychological, and social factors that reciprocally influence one another. In this article, we review two categories of studies that evaluate the contributions of psychosocial factors to the experience of chronic pain. First, we consider general psychosocial variables including distress, trauma, and interpersonal factors. Additionally, we discuss pain-specific psychosocial variables including catastrophizing, expectations, and pain-related coping. Together, we present a diverse array of psychological, social, and contextual factors and highlight the need to consider their roles in the development, maintenance, and treatment of chronic pain conditions.

Catastrophizing-a prognostic factor for outcome in patients with low back pain: a systematic review

BACKGROUND CONTEXT

Psychological factors including catastrophizing thoughts are believed to influence the development of chronic low back pain (LBP).

PURPOSE

To assess the prognostic importance of catastrophizing as a coping strategy in patients with LBP.

STUDY DESIGN

This is a systematic review.

PATIENT SAMPLE

This study included patients with LBP.

OUTCOME MEASURES

Work-related outcomes and perceived measures including return to work, pain, and disability.

METHODS

In September 2012, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, Medline, Scopus, and Web of Science. To ensure completeness of the search, a hand search and a search of bibliographies were conducted and all relevant references included. All observational studies investigating the prognostic value of catastrophizing in patients with LBP were eligible. Included were studies with 100 and more patients and follow-up of at least 3 months. Excluded were studies with poor methodological quality, short follow-up duration, and small sample size.

RESULTS

A total of 1,473 references were retrieved, and 706 references remained after the removal of duplicates. For 77 references, the full text was assessed and 19 publications based on 16 studies were included. Of four studies that investigated work-related outcomes, two found catastrophizing to be associated with work status. Most studies that investigated self-reported outcome measures (n=8, 66%) found catastrophizing to be associated with pain and disability at follow-up in acute, subacute, and chronic LBP patients. In most studies that applied cutoff values, patients identified as high catastrophizers experienced a worse outcome compared with low catastrophizers (n=5, 83%).

CONCLUSIONS

There is some evidence that catastrophizing as a coping strategy might lead to delayed recovery. The influence of catastrophizing in patients with LBP is not fully established and should be further investigated. Of particular importance is the establishment of cutoff levels for identifying patients at risk.

Are emotion regulation skills related to adjustment among people with chronic pain, independent of pain coping?

Although emotion regulation capacities have been linked to adjustment among people with chronic pain, researchers have yet to determine whether these capacities are related to functioning independent of established facets of pain coping. The present study was designed to address this gap. A sample 128 Australian adults with chronic pain (44 men, 84 women) completed self-report measures of adjustment (quality of life, negative affect, and pain-related disability), pain coping, and features of emotion regulation (emotion appraisal, perceived efficacy in emotion regulation, emotion utilization). Hierarchical multiple regression analyses indicated that efficacy in emotion regulation was related to quality of life and reduced negative affect even after statistically controlling for effects of other measures of adjustment, pain coping efficacy, and pain coping. Conversely, features of emotion regulation did not improve the prediction model for pain-related disability. Findings suggest emotion regulation capacities may have a unique role in the prediction of specific facets of adjustment among people with chronic pain.

Fusion versus nonoperative care for chronic low back pain: do psychological factors affect outcomes?

STUDY DESIGN

Systematic review.

OBJECTIVE

The objectives of this systematic review were to determine whether fusion is superior to conservative management in certain psychological subpopulations and to determine the most common psychological screening tests and their ability to predict outcome after treatment in patients with chronic lower back pain.

SUMMARY OF BACKGROUND DATA

Many studies have documented the effects of various psychological disorders on outcomes in the treatment of lower back pain. The question of whether patients with certain psychological disorders would benefit more from conservative treatment than fusion is not clear. Furthermore, the most appropriate screening tools for assessing psychological factors in the presence of treatment decision making should be recommended.

METHODS

Systematic review of the literature, focused on randomized controlled trials to assess the heterogeneity of treatment effect of psychological factors on the outcomes of fusion versus nonoperative care of the treatment of chronic low back pain. In the analysis of psychological screening tests, we searched for the most commonly reported questionnaires and those that had been shown to predict lower back pain treatment outcomes.

RESULTS

Few studies comparing fusion to conservative management reported differences in outcome by the presence or absence of a psychological disorder. Among those that did, we observed the effect of fusion compared with conservative management was more favorable in patients without a personality disorder, neuroticism, or depression. The most commonly reported, validated psychological screening tests for lower back pain are the Beck Depression Inventory, the Fear Avoidance Belief Questionnaire, the Spielberger Trait Anxiety Inventory, the Zung Depression Scale, and the Distress Risk Assessment Method.

CONCLUSION

Psychological disorders affect chronic lower back pain treatment outcomes. Patients with a personality disorder appear to respond more favorably to conservative management and those without a personality disorder more favorably to fusion. Patients with higher depression and neuroticism scores may also respond more favorably to conservative management.

CLINICAL RECOMMENDATIONS

Recommendation 1: Chronic LBP patients with depression, neuroticism, and certain personality disorders should preferentially be treated nonoperatively. Strength of recommendation: Weak. Recommendation 2: Consider the use of a validated psychological screening questionnaire such as the BDI, FABQ, DRAM, ZDI or STAI, when treating patients with CLBP. Strength of recommendation: Weak.

Targeting temporomandibular disorder pain treatment to hormonal fluctuations: a randomized clinical trial

Mounting evidence supports the importance of hormonal fluctuations in temporomandibular disorder (TMD) pain among women. Stabilizing influential hormones or having a plan and skills for coping with hormonally related increases in TMD pain, therefore, may be beneficial for women with TMD pain. This randomized clinical trial evaluated the short- and long-term efficacy of 3 interventions for women with TMD pain: (1) dental hygienist-delivered pain self-management training (SMT; n=59); (2) the same dental hygienist-delivered pain self-management training, but with a focus on menstrual cycle-related changes in pain and other symptoms (targeted SMT, or TSMT; n=55); and (3) continuous oral contraceptive therapy (6-month trial) aimed at stabilizing hormones believed to be influential in TMD pain (COCT; n=57). Study participants completed outcome (pain, activity interference, depression) and process (pain beliefs, catastrophizing, coping effectiveness) measures before randomization, and 6 and 12months later. Intent-to-treat analyses supported the benefits of the SMT and TSMT interventions relative to COCT. Targeting the self-management treatment to menstrual cycle-related symptoms did not increase the treatment's efficacy. The benefits of the self-management interventions relative to COCT for pain and activity interference were statistically significant at 12 months, but not at 6 months, whereas the benefits for the process measures generally were apparent at both time points. COCT was associated with multiple adverse events (none serious). The study provides further support for long-term benefits of a safe, low-intensity (2 in-person sessions and 6 brief telephone contacts), dental hygienist-delivered self-management treatment for TMD pain.

RTW in back conditions

PURPOSE

Back conditions are a group of impairments that induce limitation of activities and restriction of participation, in particular delaying the Return to work (RTW). The purpose of this review is to analyse the components involved in RTW.

METHOD

We have included the studies and reviews about the intervention, assessment tools, variables used to forecast the RTW and the cost-benefit ratio.

RESULTS

We found a relevant number of studies concerning back conditions and Return to work. The evidence is moderate and the meta-analysis failed to show strong indications of efficacy. The better interventions to facilitate RTW are multidisciplinary, not necessarily intensive but taking into account a bio-psycho-social approach. The predictor of RTW does not only concern impairment (pain, rigidity etc.), but the self-estimation of ability is also important to forecast RTW. Intervention seems to be cost-effective if we calculate the saving cost in pension.

CONCLUSIONS

Comprehensive bio-psycho-social approaches seem to be the better modality of intervention to facilitate the RTW. More research is needed to obtain more knowledge about these issues. Particular attention should be placed on the choice of outcome measures and the cost-effectiveness of interventions.

Patient-preference disability assessment for disabling chronic low back pain: a cross-sectional survey

STUDY DESIGN

A cross sectional survey. OBJECTIVE.: To assess patient priorities in disability and restriction in participation with disabling chronic low back pain (CLBP) by use of the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR) and to compare this questionnaire with other outcome measures widely used in this situation.

SUMMARY OF BACKGROUND DATA

Disability and participation restriction are widely assessed in CLBP but do not account for patient priorities. Knowing what is important to patients could be useful to help form treatment goals and plans.

METHODS

A total of 150 patients hospitalized in a tertiary care teaching hospital for the management of CLBP were enrolled in the study. Evaluation was by the MACTAR, the Quebec Back Pain Disability Questionnaire (QUEBEC), the Hospital Anxiety and Depression scale, the Fear-Avoidance Beliefs Questionnaire, the Coping Strategies Questionnaire, and pain and handicap visual analog scales. Correlations between the MACTAR score and scores for other scales were analyzed by the Spearman coefficient.

RESULTS

On the MACTAR, patients with CLBP cited as most important 3 disability domains classified by the International Classification of Functioning, Disability, and Health: mobility (n = 23 activities, 165 times, 33% of the patients); community, social, and civic life (n = 7 activities, 138 times, 27.6% of the patients); and domestic life (n = 10 activities, 123 times, 24.6% of the patients). Patients ranked first in importance 37 different activities, especially sport (n = 29 times; 19.3% of the patients), shopping (n = 14; 9.3% of the patients), and walking (n = 13; 8.7% of the patients). The MACTAR score was correlated moderately with visual analog scale handicap (r = 0.51), weakly with the QUEBEC score (r = 0.40), and not at all with Hospital Anxiety and Depression scale, Fear-Avoidance Beliefs Questionnaire, and Coping Strategies Questionnaire scores.

CONCLUSION

For assessing priorities in disability and participation restriction among patients with CLBP, the MACTAR has acceptable construct validity. The weak correlation between QUEBEC and MACTAR scores suggests that the latter scale adds useful information for assessing the health priorities of disabled CLBP patients.

Self-reported severity measures as predictors of return-to-work outcomes in occupational back pain

INTRODUCTION

We test an array of biopsychosocial, cognitive-behavioral, and work-related factors to identify the best predictors of work disability following a back injury.

METHODS

We test the validity of alternative severity measures in predicting the likelihood of four distinct, mutually exclusive patterns of post-injury employment in the first year after onset of back pain. The study sample includes 959 participants in the ASU Healthy Back Study, a prospective cohort study of workers who filed claims for occupational back pain between 1999 and 2002. Self-reported severity measures include: NRS-101 measures of the intensity of back or leg pain, Roland-Morris scale of functional disability, and mental and physical components of the SF-12.

RESULTS

All the severity measures have significant predictive power on return-to-work outcomes even after 1 year. Baseline physical functioning and overall mental and physical health status are more predictive of specific patterns of post-injury employment than pain intensity measures, possibly because there is considerable idiosyncratic variation in the pain intensity measures. The mental component of the SF-12, in particular, is relatively robust to alternate specifications, consistently statistically significant, and has the lowest probability significance level in explaining patterns of employment 1 year after injury.

Changes after multidisciplinary pain treatment in patient pain beliefs and coping are associated with concurrent changes in patient functioning

Little is known about how patient functioning changes after completion of multidisciplinary pain programs, and what factors are associated with such changes when they occur; for example, whether improvement or deterioration in functioning corresponds to changes in patient beliefs and coping during this period. The objective of this study was to examine the extent to which changes in patient pain and functioning were associated with changes in beliefs and coping after multidisciplinary pain treatment. Patients with chronic pain (N=141) completed outcome (pain, functioning) and process (beliefs, catastrophizing, coping) measures at the end of multidisciplinary pain treatment and 12 months posttreatment. On average, patients reported similar levels of pain at both times, but showed a small worsening in disability and depression outcomes between posttreatment and follow-up, which were associated significantly with concurrent changes in the process measures. In particular, increased belief in oneself as disabled by pain, catastrophizing, and increased use of resting, guarding and asking for assistance in response to pain were linked with increased disability and depression. Decreased perceived control over pain was also consistently associated with worsening of these outcomes. The results highlight the potential importance of specific pain-related beliefs and coping responses in long-term patient pain and adjustment. Research is needed to determine whether booster interventions after the end of intensive multidisciplinary treatment that target these beliefs and coping responses improve long-term outcomes.

Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain

Although cognitive-behavioral therapies (CBT) have been demonstrated to be effective for a variety of chronic pain problems, patients vary in their response and little is known about patient characteristics that predict or moderate treatment effects. Furthermore, although cognitive-behavioral theory posits that changes in patient beliefs and coping mediate the effects of CBT on patient outcomes, little research has systematically tested this. Therefore, we examined mediators, moderators, and predictors of treatment effects in a randomized controlled trial of CBT for chronic temporomandibular disorder (TMD) pain. Pre- to post-treatment changes in pain beliefs (control over pain, disability, and pain signals harm), catastrophizing, and self-efficacy for managing pain mediated the effects of CBT on pain, activity interference, and jaw use limitations at one year. In individual mediator analyses, change in perceived pain control was the mediator that explained the greatest proportion of the total treatment effect on each outcome. Analyzing the mediators as a group, self-efficacy had unique mediating effects beyond those of control and the other mediators. Patients who reported more pain sites, depressive symptoms, non-specific physical problems, rumination, catastrophizing, and stress before treatment had higher activity interference at one year. The effects of CBT generally did not vary according to patient baseline characteristics, suggesting that all patients potentially may be helped by this therapy. The results provide further support for cognitive-behavioral models of chronic pain and point to the potential benefits of interventions to modify specific pain-related beliefs in CBT and in other health care encounters.

Validating the Use of Two-Item Measures of Pain Beliefs and Coping Strategies for a Veteran Population

Previous research has demonstrated that 2-item versions of subscales from the Chronic Pain Coping Inventory, Coping Strategy Questionnaire, and the Survey of Pain Attitudes appear adequately reliable and valid for use in studies with large sample sizes. It was suggested that use of the abbreviated scales might help to expand the testing and application of cognitive-behavioral models of pain to new settings and with new populations where assessment burden might be a key issue. This study explored the utility of these brief scales among veterans in a Veterans Affairs setting. Strong associations were found between the 2-item versions and their respective parent scales. In addition, the 2-item scales were found to be associated with other pain-related measures, supporting their predictive validity. The results of this study replicate previous findings and offer support for the use of the 2-item versions for both screening and research purposes in Veterans Affairs settings with a veteran population.

PERSPECTIVE

This article presents the psychometric properties of brief versions of 3 commonly used pain coping and belief questionnaires in a unique population. These measures could be used clinically for initial screening purposes, as well as for treatment monitoring.

Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: a randomized, controlled trial

We evaluated the short- and long-term efficacy of a brief cognitive-behavioral therapy (CBT) for chronic temporomandibular disorder (TMD) pain in a randomized controlled trial. TMD clinic patients were assigned randomly to four sessions of either CBT (n=79) or an education/attention control condition (n=79). Participants completed outcome (pain, activity interference, jaw function, and depression) and process (pain beliefs, catastrophizing, and coping) measures before randomization, and 3 (post-treatment), 6, and 12 months later. As compared with the control group, the CBT group showed significantly greater improvement across the follow-ups on each outcome, belief, and catastrophizing measure (intent-to-treat analyses). The CBT group also showed a greater increase in use of relaxation techniques to cope with pain, but not in use of other coping strategies assessed. On the primary outcome measure, activity interference, the proportion of patients who reported no interference at 12 months was nearly three times higher in the CBT group (35%) than in the control group (13%) (P=0.004). In addition, more CBT than control group patients had clinically meaningful improvement in pain intensity (50% versus 29% showed > or =50% decrease, P=0.01), masticatory jaw function (P<0.001), and depression (P=0.016) at 12 months (intent-to-treat analyses). The two groups improved equivalently on a measure of TMD knowledge. A brief CBT intervention improves one-year clinical outcomes of TMD clinic patients and these effects appear to result from specific ingredients of the CBT.

Psycho-social factors and coping strategies as predictors of chronic evolution and quality of life in patients with low back pain: a prospective study

Low back pain (LBP) is a major problem of public health. Chronic pain is the most difficult to treat and the most expensive. The way patients cope with their pain may influence its outcome.

AIM

To identify coping strategies of LBP patients, and their influence on LBP evolution.

METHODS

Ninety nine patients were assessed just after an acute LBP episode and one year later. Assessment tools included medical and social reports, scales of anxiety, depression, quality of life, locus of control (LOC), social support and coping strategies.

RESULTS

One year after the initial episode, 67% of patients have improved and 33% had a chronic pain. A principal components analysis showed that two main dimensions might be identified inside the outcome: functional and emotional non-adjustment. Functional non-adjustment was predicted by male gender, reduction of activity, and history of trauma over one year. Emotional non-adjustment was only predicted by trait-depression. Reactions to pain were structured in four factors: distraction-praying, helplessness-hopelessness, cognitive restructuration and perceived control. Two of these factors predicted adjustment one year later: distraction-praying had a direct effect on functional non-adjustment, and helplessness-hopelessness on emotional issue.

CONCLUSIONS

Besides somatic factors, psychosocial predictors of LBP chronic evolution may be identified. Both aspects must be taken into account in order to prevent chronic pain. Perhaps cognitive-behavior therapy may help LBP patients to cope with pain in a better way.

Further validation of the chronic pain coping inventory

Multidisciplinary treatment programs for chronic pain typically emphasize the importance of decreasing maladaptive and encouraging adaptive coping responses. The Chronic Pain Coping Inventory (CPCI), developed to assess coping strategies targeted for change in multidisciplinary pain treatment, is a 64-item instrument that contains 8 subscales: Guarding, Resting, Asking for Assistance, Relaxation, Task Persistence, Exercising/Stretching, Coping Self-Statements, and Seeking Social Support. A previous validation study with 210 patients in a Canadian academic hospital setting supported an 8-factor structure for the CPCI. The current study was undertaken to validate the CPCI among 564 veterans with a more extended history of chronic pain. Patients completed the study questionnaires before multidisciplinary treatment. A confirmatory factor analysis was used to examine the factor structure of the 64-item CPCI. A series of hierarchical multiple regression analyses were performed with depression, pain interference, general activity level, disability, and pain severity as the criterion variables and the 8 CPCI factors as the predictor variables, controlling for pain severity and demographic variables. The confirmatory factor analysis results strongly supported an 8-factor model, and the regression analyses supported the predictive validity of the CPCI scales, as indicated by their association with measures of patient adjustment to chronic pain.

PERSPECTIVE

This article validated the 8-factor structure of the CPCI by using a confirmatory factor analysis and a series of linear regressions. The results support the applicability and utility of the CPCI in a heterogeneous population of veterans with severe chronic pain treated in a tertiary teaching hospital. The CPCI provides an important clinical and research tool for the assessment of behavioral pain coping strategies that might have an impact on patient outcomes.

A systematic review of sociodemographic, physical, and psychological predictors of multidisciplinary rehabilitation-or, back school treatment outcome in patients with chronic low back pain

STUDY DESIGN

A systematic review.

OBJECTIVE

To determine predictors of outcome of multidisciplinary rehabilitation-or back school treatment for patients with chronic low back pain.

SUMMARY OF BACKGROUND DATA

Numerous reviews have been performed to gain insight into which patients benefit from which treatment. However, no review has systematically focused on predictors from multiple domains (i.e., sociodemographic, physical, and psychological), or on treatment outcome measured as activity limitation or participation restriction.

METHODS

Studies were found by searching medical and psychological databases, and screening references. Two reviewers independently assessed the methodological quality using standard criteria. Studies were only included if they met a predefined level of internal validity. A qualitative analysis was performed.

RESULTS

Heterogeneity among studies in patient characteristics, predictors, treatment, and outcomes limited evidence. All reviewed studies were descriptive or exploratory in nature. Consistent evidence was found for the predictive value of pain intensity (more pain--> worse outcome), several work-related parameters (e.g., high satisfaction--> better outcome), and coping style (less active coping--> better outcome). Other sociodemographic and physical variables consistently lacked predictive value. No consistent evidence was found for other psychological variables.

CONCLUSIONS

It is impossible to define a generic set of predictors of outcome of multidisciplinary rehabilitation and back schools for patients with chronic low back pain because the reviewed studies were descriptive or exploratory in nature, and most predictors were only studied once. Nevertheless, for several predictors, consistent evidence was found. Large confirmatory studies are needed to test the value of these predictors.

Ethnic differences in pain coping: factor structure of the coping strategies questionnaire and coping strategies questionnaire-revised

Coping has been examined extensively in the pain literature, although coping instruments have been typically validated in clinical populations with little ethnic diversity. This study examined the factor structure of the Coping Strategies Questionnaire (CSQ) and the CSQ-Revised (CSQ-R) in 650 healthy male and female African American (44%) and white (56%) subjects and explored associations of coping to health and pain-related measures. Factor analyses revealed 6 components for each ethnic group, accounting for comparable amounts of variance and resembling previously reported CSQ subscales. Internal consistency for both ethnic groups was acceptable (0.72-0.91). There were significant main effects for ethnicity on 4 of the CSQ-R scales (P < .05). No ethnic differences in pain or health variables emerged, although when split into high-pain versus minimal-pain groups, differences were revealed on catastrophizing. Results indicate that the factor structure of the CSQ-R in healthy adults is similar to clinical populations and is comparable across African American and white subjects. Group differences on CSQ-R scales suggest potentially important ethnic influences on pain coping. These findings support the use of the CSQ-R to assess coping in African Americans and in healthy young adults. Additional clinical research is needed to determine the practical importance of group differences in pain coping.

PERSPECTIVE

Coping has been examined extensively in the pain literature, although coping instruments typically have been validated in clinical populations with little ethnic diversity. This study examines the factor structure of the CSQ-Revised in an ethnically diverse population and supports the use of the CSQ-R to assess coping in African Americans and in healthy young adults.

Pain-related catastrophizing: a daily process study

Little is known about the extent to which individuals vary versus remain stable in their pain-related catastrophizing, or to which catastrophizing is associated with pain and related problems on a daily basis. We used daily electronic interviews to examine the: (1) reliability and validity of a brief daily catastrophizing measure; (2) stability of catastrophizing; (3) patient characteristics associated with catastrophizing; (4) associations between catastrophizing and concurrent and subsequent outcomes (pain, activity interference, jaw use limitations, and negative mood), between and within patients; and (5) associations between pain and subsequent catastrophizing. One hundred patients with chronic temporomandibular disorder pain completed electronic interviews three times a day for 2 weeks [mean (SD) number of interviews=46 (15)]. The catastrophizing scale had high internal consistency (Cronbach's alpha = 0.95) and validity (r = 0.65 with the Coping Strategy Questionnaire Catastrophizing scale), and catastrophizing was stable (ICC=0.72) over time. Younger age and greater baseline depression, pain, and disability predicted greater daily catastrophizing. Daily catastrophizing was associated significantly with concurrent outcomes, between- and within-subjects (P < 0.001); however, associations with same-day subsequent outcomes were greatly attenuated after adjusting for prior outcome levels. Similarly, daily pain was associated significantly with subsequent catastrophizing, but this association was no longer statistically significant after adjusting for prior catastrophizing. The data indicate that catastrophizing is stable over short periods of time in the absence of substantial change in pain, and that within patients, times of greater catastrophizing are associated with worse pain, disability, and mood.

Chronic pain self-management for older adults: a randomized controlled trial [ISRCTN11899548]

BACKGROUND

Chronic pain is a common and frequently disabling problem in older adults. Clinical guidelines emphasize the need to use multimodal therapies to manage persistent pain in this population. Pain self-management training is a multimodal therapy that has been found to be effective in young to middle-aged adult samples. This training includes education about pain as well as instruction and practice in several management techniques, including relaxation, physical exercise, modification of negative thoughts, and goal setting. Few studies have examined the effectiveness of this therapy in older adult samples.

METHODS/DESIGN

This is a randomized, controlled trial to assess the effectiveness of a pain self-management training group intervention, as compared with an education-only control condition. Participants are recruited from retirement communities in the Pacific Northwest of the United States and must be 65 years or older and experience persistent, noncancer pain that limits their activities. The primary outcome is physical disability, as measured by the Roland-Morris Disability Questionnaire. Secondary outcomes are depression (Geriatric Depression Scale), pain intensity (Brief Pain Inventory), and pain-related interference with activities (Brief Pain Inventory). Randomization occurs by facility to minimize cross-contamination between groups. The target sample size is 273 enrolled, which assuming a 20% attrition rate at 12 months, will provide us with 84% power to detect a moderate effect size of.50 for the primary outcome.

DISCUSSION

Few studies have investigated the effects of multimodal pain self-management training among older adults. This randomized controlled trial is designed to assess the efficacy of a pain self-management program that incorporates physical and psychosocial pain coping skills among adults in the mid-old to old-old range.

One- and two-item measures of pain beliefs and coping strategies

Pain-related beliefs and pain coping strategies are central components of current cognitive-behavioral models of chronic pain, and have been found in numerous studies to be associated significantly with psychosocial and physical disability. However, the length of most measures of pain-related beliefs and coping restricts the ability of clinicians and researchers to perform a thorough assessment of these variables in many situations. The availability of very brief versions of existing scales would make possible the assessment of a range of important pain beliefs and coping strategies in settings where subject or patient assessment burden is an issue. In this study, one- and two-item versions of the subscales of several commonly used measures of pain beliefs and coping strategies were developed using both rational and empirical procedures. The findings support the validity of these brief subscales. The appropriate use and limitations of these measures are discussed.

Readiness to self-manage pain is associated with coping and with psychological and physical functioning among patients with chronic pain

A patient's readiness to adopt a self-management approach to pain has been suggested as a construct that may explain differences among patients in coping, adjustment, and response to multidisciplinary pain treatment. The pain stages of change questionnaire (PSOCQ; Pain, 72 (1997) 227) was designed to assess four components of this construct. The current study tested the following two hypotheses in two different samples of persons with chronic pain. PSOCQ scales are associated with (1) coping strategies used to manage pain and (2) patient disability and depression. The findings supported the first hypothesis and provided mixed support for the second. The implications of the findings for understanding the readiness to self-manage pain construct and the validity of the PSOCQ for assessing this construct are discussed.

The Chronic Pain Coping Inventory-42: reliability and validity

Coping responses have been shown to be associated with physical and psychological functioning in patients with chronic pain. Assessment of coping strategies has received increasing attention, with several measures of cognitive and behavioral coping showing promise. One such instrument is the Chronic Pain Coping Inventory (Pain 60 (1995) 203), a 65-item measure of behavioral and cognitive pain coping strategies often targeted as part of multidisciplinary pain treatment. Initial research has supported the reliability and validity of the CPCI. This article describes the development of an abbreviated (42-item) CPCI. The results demonstrate very high correlations between the original and abbreviated CPCI scales, as well as comparable internal consistency, test-retest stability, and validity coefficients. The findings support the reliability and validity of the abbreviated CPCI, and suggest that it could be substituted for the CPCI without sacrificing reliability and validity in situations where a briefer measure of coping with chronic pain is preferable.

Chronic pain and coping: a proposed role for nurses and nursing models

AIMS

Activity of living based nurse models such as that proposed by Roper, Logan and Tierney are utilized commonly to rationalize, structure and guide practice. This paper proposes that their use, in the context of chronic pain, should be extended to incorporate the assessment of coping and its effect on disability.

BACKGROUND

As coping has been found to account for some of the variance in adaptation to chronic pain, generic models of coping and their utility in this context are considered. The need for reliable and valid means to assess coping are of paramount importance as this will facilitate and inform treatment and management of chronic pain. At the present time coping is most generally assessed using self report instruments which primarily focus on the number and type of strategies used to cope rather than their effectiveness in reducing disability and increasing function.

FINDINGS

A classification system which categorizes chronic pain patients in terms of how they function in daily life as either adaptive copers, interpersonally distressed or dysfunctional is outlined. The similarities between this and a routine nursing assessment based on an activities of living model are highlighted.

CONCLUSIONS

It is proposed that the innovative use of nursing activity of living models could provide the framework for a pain clinic based assessment of coping that has greater utility for professionals and patients alike.

The roles of beliefs, catastrophizing, and coping in the functioning of patients with temporomandibular disorders

Pain-related beliefs, catastrophizing, and coping have been shown to be associated with measures of physical and psychosocial functioning among patients with chronic musculoskeletal and rheumatologic pain. However, little is known about the relative importance of these process variables in the functioning of patients with temporomandibular disorders (TMD). To address this gap in the literature, self-report measures of pain, beliefs, catastrophizing, coping, pain-related activity interference, jaw activity limitations, and depression, as well as an objective measure of jaw opening impairment, were obtained from 118 patients at a TMD specialty clinic. Controlling for age, gender, and pain intensity, significant associations were found between (1) pain beliefs and activity interference, depression, and non-masticatory jaw activity limitations, (2) catastrophizing and activity interference, depression, and non-masticatory jaw activity limitations, and (3) coping and activity interference and depression. Controlling for age, gender, pain intensity, and the other process variables, significant associations were found between (1) beliefs and activity interference and depression, and (2) catastrophizing and depression. No process variable was associated significantly with the objective measure of jaw impairment. The results suggest that for patients with moderate or high levels of TMD pain and dysfunction, beliefs about pain play an important role in physical and psychosocial functioning.

Coping strategies, pain, and disability in patients with hemophilia and related disorders

OBJECTIVE

To analyze the use of various coping strategies in homogeneous groups of patients with hemophilia and von Willebrand's disease and to investigate the relationship between the state of the disease, the use of coping strategies, and management of the disease.

METHODS

The coping strategies measured by the Coping Strategies Questionnaire were analyzed in 3 homogeneous groups of 224 patients. Psychosocial well-being (PWB) measured by the Rand 36-item Health Survey 1.0 was used as an indicator of management of the disease. The pain factor consisted of the following variables: pain intensity, use of analgesics, Functional Disability Index, and physical activity level.

RESULTS

The groups of patients differed significantly only in the use of the catastrophizing strategy (CAT). In all pain groups, distraction was the most commonly used coping strategy. A significant interaction effect of pain factor and age on PWB (P = 0.04) was found. The mediating function of the CAT strategy was confirmed by the series of regression analyses.

CONCLUSION

The coping strategy profile in hemophilia was found to be similar to those in other chronic pain states. The use of the strategies does not depend on the severity of the disease. We confirmed the role of age and the use of the CAT strategy as, respectively, moderator and mediator in the pattern of relationships between the clinical state of the disease and psychosocial well-being.

Coping with neck and low back pain in the general population

This study had 2 objectives: (a) to assess the psychometric properties of the Pain Management Inventory (PMI; G. K. Brown & P. M. Nicassio, 1987) with individuals in the general population with neck or low back pain, and (b) to assess the relationship between pain severity and coping. Data were taken from a mailed survey of a random sample of adults residing in Saskatchewan, Canada. Results validated the 2-factor structure of the PMI and provided evidence for the internal consistency of the coping subscales. Regression analyses revealed that passive coping was associated with being married, greater pain severity, depression, and poor health. Active coping was associated with female gender, higher education, less depression, good health, and frequent exercise. This study provides psychometric data to support the use of the PMI and information about factors associated with use of active and passive coping strategies in pain sufferers.

Do beliefs, coping, and catastrophizing independently predict functioning in patients with chronic pain?

Physical and psychosocial disability in patients with chronic pain have been shown to be associated with patients' pain-related beliefs, tendency to catastrophize, and pain coping strategy use. However, little is known about whether beliefs, catastrophizing, and coping strategies are independently associated with patient adjustment. Identification of specific beliefs, cognitive responses, and coping strategies strongly and independently associated with physical and psychosocial functioning would suggest the importance of targeting those variables for modification in treatment. One hundred sixty-nine patients entering a multidisciplinary pain treatment program completed measures of pain, beliefs, coping, catastrophizing, physical disability, and depression. Principal components analyses were used to create belief and coping components, which were then entered in multiple regression analyses predicting physical disability and depression. Belief scores significantly and independently predicted both physical disability and depression, after controlling for age, sex, pain intensity, catastrophizing, and coping. Coping scores significantly and independently predicted physical disability, but not depression, whereas catastrophizing independently predicted depression, but not physical disability. These findings suggest the importance of targeting specific pain-related beliefs and coping strategies, as well as catastrophizing, for modification in the treatment of patients with chronic pain.

Factors associated with anxiety and depression in facial arthromyalgia

Facial arthromyalgia (temporomandibular joint pain dysfunction syndrome, TMD) is a chronic pain condition of unknown origin. This paper examines the extent to which the condition is associated with symptoms of anxiety and depression. It also identifies factors which may be predictive of raised levels of these two moods and of the presence of clinical anxiety and clinical depression. Self-report measures of pain beliefs, coping strategies, pain intensity, disability and mood were administered to a sample of 80 facial arthromyalgia patients of differing chronicity. The results showed anxious mood to be associated with several factors including beliefs that pain is itself worsened by negative mood, passive coping in terms of catastrophising about pain, and speech problems. Depressed mood was associated with catastrophising and disability in the form of disturbance in taste and digestion. These factors may be considered as potential targets for therapy, rather than the orthodox objective of pain relief.

Age, pain, and coping with rheumatoid arthritis

The purpose of this study was to examine the relationship of age and pain severity (i.e. mild versus severe pain) in predicting coping strategies of individuals with rheumatoid arthritis (RA). An age-stratified sample (N = 121) of individuals diagnosed with rheumatoid arthritis completed a modified version of the Coping Strategies Questionnaire (CSQ). Individuals were asked to report the coping strategies used for mild versus severe pain. Findings included: (1) older adults were more likely than younger adults to report use of maladaptive coping strategies in the context of mild, but not severe, RA pain, (2) older adults' reported patterns of coping reflected less-than-anticipated expertise in dealing with RA pain, and (3) individuals, regardless of age, reported use of more active coping strategies in the context of mild pain and use of more maladaptive coping strategies in the context of severe pain. The present study suggests that research regarding illness and coping is most informative when it captures the individual-situational interaction of dealing with stressors such as chronic pain.