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.     

Further evaluation of the pain stages of change questionnaire: is the transtheoretical model of change useful for patients with chronic pain?

Patient readiness to adopt new beliefs and coping responses to pain may predict response to multidisciplinary or cognitive-behavioral pain treatments that emphasize changes in beliefs and coping behaviors. According to the transtheoretical model of change, individuals go through specific stages in the process of changing maladaptive behaviors. Based on this model, Kerns et al. (1997) (Kerns RD, Rosenberg R, Jamison RN, Caudill MA, Haythornthwaite J. Readiness to adopt a self-management approach to chronic pain: the Pain Stages of Change Questionnaire (PSOCQ). Pain 1997;72:227-234) developed a measure of readiness to adopt a self-management approach to pain problems (the Pain Stages of Change Questionnaire; PSOCQ) and provided preliminary data supporting the validity of the measure. The current study sought to further evaluate the PSOCQ by determining the generalizability of these preliminary findings and the ability of the PSOCQ to classify persons with chronic pain into specific stages of readiness to self-manage pain. One hundred ten patients with diverse chronic pain problems, and 119 patients with fibromyalgia completed the PSOCQ and two measures of pain-related beliefs and coping prior to entry into two separate multidisciplinary pain programs. The internal consistency and concurrent validity of the PSOCQ subscales were largely replicated, supporting the validity of the subscales as measures of readiness to self-manage pain. However, the PSOCQ demonstrated less utility as a tool for classifying individuals into one of four specific stages of readiness to adopt a self-management approach. This result may be due to the classification procedure used in the current study, the characteristics of the samples in the study, specific limitations of the measure, and/or limitations in the applicability of the transtheoretical model of change to patients with chronic pain.     

Changes in willingness to self-manage pain among children and adolescents and their parents enrolled in an intensive interdisciplinary pediatric pain treatment program

The importance of willingness to adopt a self-management approach to chronic pain has been demonstrated in the context of cognitive-behaviorally oriented interdisciplinary pain treatment programs for adults, both as a treatment outcome and as a process that facilitates functional improvements. Willingness to self-manage pain has not been studied in pediatric interdisciplinary pain treatment settings. Study aims were (1) to investigate willingness to self-manage pain among children and parents undergoing intensive interdisciplinary pain treatment and (2) to determine whether increased willingness to self-manage pain influenced functional treatment outcomes. A total of 157 children ages 10 to 18 and their parents enrolled in a pediatric pain rehabilitation program completed the Pain Stages of Change Questionnaire (PSOCQ youth and parent versions) at pretreatment, posttreatment, and short-term follow-up. They also reported on pain, functional disability, depressive symptoms, fear of pain, and use of passive and accommodative coping strategies. Results show that willingness to self-manage pain increased during treatment among both children and parents, with gains maintained at follow-up. Increases in children's readiness to self-manage pain from pretreatment to posttreatment were associated with decreases in functional disability, depressive symptoms, fear of pain, and use of adaptive coping strategies. Increases in parents' readiness to adopt a pain self-management approach were associated with changes in parent-reported fear of pain but not with other child outcomes. Few associations emerged between pretreatment willingness to self-manage pain and posttreatment outcomes. Findings suggest that interdisciplinary pediatric pain rehabilitation may facilitate increased willingness to self-manage pain, which is associated with improvements in function and psychological well-being.     

Predicting responses to self-management treatments for chronic pain: application of the pain stages of change model

Psychological treatments emphasizing a self-management approach have become commonly accepted alternatives to medical interventions for chronic pain. Unfortunately, these approaches often fail to engage a significant portion of targeted individuals and are associated with high drop-out and relapse rates. Informed by the transtheoretical model of behavior change and the cognitive behavioral perspective on chronic pain, the Pain Stages of Change Questionnaire (PSOCQ) was developed to assess readiness to adopt a self-management approach to chronic pain. Initial studies supported the reliability and validity of four distinct scales, Precontemplation, Contemplation, Action and Maintenance. The current study was designed to assess the ability of the PSOCQ to predict self-management participation and outcome. The PSOCQ and several relevant outcome measures were assessed before and after self-management treatment by 109 chronic pain patients. Profile analysis revealed that treatment completers and non-completers differed significantly across the four PSOCQ scales. Post-hoc comparisons indicated that pretreatment PSOCQ Precontemplation and Contemplation scores discriminated these two groups. Separate analyses revealed that Action and Maintenance scores increased over the course of treatment, and that changes in the PSOCQ scales were associated with improved outcomes. These findings suggest that increased commitment to a self-management approach to chronic pain may serve as a mediator or moderator of successful treatment. This study supports the predictive validity and utility of the PSOCQ, as well as the relevance of the stages of change model to self-management of chronic pain.     

Randomized trial of a DVD intervention to improve readiness to self-manage joint pain

A DVD (digital video disk) intervention to increase readiness to self-manage joint pain secondary to hemophilia was informed by a 2-phase, motivational-volitional model of readiness to self-manage pain, and featured the personal experiences of individuals with hemophilia. The DVD was evaluated in a randomized controlled trial in which 108 men with hemophilia completed measures of readiness to self-manage pain (Pain Stages of Change Questionnaire) before and 6 months after receiving the DVD plus information booklet (n = 57) or just the booklet (n = 51). The effect of the DVD was assessed by comparing changes in Pain Stages of Change Questionnaire scores (precontemplation, contemplation, and action/maintenance) between groups. The impact on pain coping, pain acceptance, and health-related quality of life was tested in secondary analyses. Repeated-measures analysis of variance, including all those with complete baseline and follow-up data regardless of use of the intervention, showed a significant, medium-sized, group × time effect on precontemplation, with reductions among the DVD group but not the booklet group. Significant use × time effects showed that benefits in terms of contemplation and action/maintenance were restricted to those who used the interventions at least once. The results show that low-intensity interventions in DVD format can improve the motivational impact of written information, and could be used to help prepare people with chronic pain for more intensive self-management interventions. The findings are consistent with a 2-phase, motivational-volitional model of pain self-management, and provide the first insights to our knowledge of readiness to self-manage pain in hemophilia.     

Readiness to change in pediatric chronic pain: initial validation of adolescent and parent versions of the Pain Stages of Change Questionnaire

Despite the clinical importance of readiness to change in predicting treatment outcomes among adults, no studies have examined this construct among pediatric pain patients. Because parents play a key role in adolescent pain management, both adolescent and parent readiness to adopt a self-management approach to pain merit further study. The primary goal of the current study was to validate adolescent and parent-report adaptations of the adult Pain Stages of Change Questionnaire (PSOCQ). Participants included 259 adolescent patients with chronic pain syndromes and their parents presenting to 2 pediatric pain management clinics. Using confirmatory factor analytic techniques, a 4-factor solution was supported for the parent version (PSOCQ-P) that included Precontemplation, Contemplation, Action, and Maintenance factors, whereas the adolescent version (PSOCQ-A) version supported a three-factor model that combines the Action and Maintenance scales. Within both versions, each of the factors was found to be internally consistent. The PSOCQ-A and PSOCQ-P showed evidence of criterion validity through significant correlations with coping strategies and pain catastrophizing. Stability findings at 4 and 8 weeks after a multidisciplinary pain clinic evaluation are reported. Associations between pediatric PSOCQ scores and demographic, pain, and functional domains were explored to inform future research. Further validation of the PSOCQ-A and PSOCQ-P measures with new, separate samples of pediatric pain patients and parents are needed before use in clinical contexts.     

Predicting readiness to self-manage pain

OBJECTIVE: The goal of multidisciplinary treatment for chronic pain is to help patients actively self-manage pain. In this study, we examined predictors of 2 measures of readiness to self-manage pain, namely the Precontemplation and Action subscales of the Pain Stages of Change Questionnaire. In particular, we examined the relative importance of experiences with pain and the primary care physician and beliefs about self-efficacy and pain control in predicting intention to self-manage pain (Precontemplation) and actual use of pain self-management strategies (Action). METHOD: One hundred and two chronic pain participants, from 4 multidisciplinary rehabilitation centers, completed the Precontemplation and Action subscales. They also completed self-report questionnaires assessing pain severity, interference, depression, pain-related anxiety, perceptions of the patient-physician relationship, pain locus of control beliefs, and pain self-efficacy. RESULTS: Considerable variance in Precontemplation scores (49%) was explained by the variables studied. Beliefs about powerful others controlling pain and perceptions of low internal control were particularly salient in the prediction of Precontemplation scores. Less variance was explained in Action scores (35%). Satisfaction with information provided by the physician was uniquely related to Action scores. DISCUSSION: The results of the study are placed within the context of the Motivational Model of Pain Self-Management and provide insight into factors that are associated with motivation to self-manage pain. Future directions for research are discussed with respect to perceptions of pain control and satisfaction with information from physicians, constructs which have previously been overlooked in research on motivation to self-manage pain.     

Treatment outcome in individuals with chronic pain: is the Pain Stages of Change Questionnaire (PSOCQ) a useful tool?

The efficacy of psychological treatments emphasising a self-management approach to chronic pain has been demonstrated by substantial empirical research. Nevertheless, high drop-out and relapse rates and low or unsuccessful engagement in self-management pain rehabilitation programs have prompted the suggestion that people vary in their readiness to adopt a self-management approach to their pain. The Pain Stages of Change Questionnaire (PSOCQ) was developed to assess a patient's readiness to adopt a self-management approach to their chronic pain. Preliminary evidence has supported the PSOCQ's psychometric properties. The current study was designed to further examine the psychometric properties of the PSOCQ, including its reliability, factorial structure and predictive validity. A total of 107 patients with an average age of 36.2 years (SD=10.63) attending a multi-disciplinary pain management program completed the PSOCQ, the Pain Self-Efficacy Questionnaire (PSEQ) and the West Haven-Yale Multidimensional Pain Inventory (WHYMPI) pre-admission and at discharge from the program. Initial data analysis found inadequate internal consistencies of the precontemplation and action scales of the PSOCQ and a high correlation (r=0.66, P<0.01) between the action and maintenance scales. Principal component analysis supported a two-factor structure: 'Contemplation' and 'Engagement'. Subsequent analyses revealed that the PSEQ was a better predictor of treatment outcome than the PSOCQ scales. Discussion centres upon the utility of the PSOCQ in a clinical pain setting in light of the above findings, and a need for further research.     

Stages of change in readiness to adopt a self-management approach to chronic pain: the moderating role of early-treatment stage progression in predicting outcome

Relative readiness to assume a self-management approach to chronic pain can be conceptualised as a stage model. Although both initial stage (precontemplation, action) and changes in attitudes reflecting stage orientation have been shown to predict treatment outcome, the joint contributions of these factors need to be examined. Sixty-five chronic pain patients, participating in a 4-week multidisciplinary pain program, completed the Pain Stages of Change Questionnaire (PSOCQ), subscales of the Multidimensional Pain Inventory, and the Beck Depression Inventory at pre-, mid- and post-treatment. Patients were assigned to stage group (precontemplation or action) based on whether their Precontemplation or Action subscale scores were highest. Results showed that: (a) stage group interacted with pre- to mid-treatment Precontemplation subscale changes to predict mid- to late-treatment pain severity and interference changes such that precontemplation attitude decreases were related to reduced pain and interference only among patients who were already action stage at pre-treatment; (b) stage group interacted with pre- to mid-treatment Action subscale changes to predict mid- to late-treatment interference and activity changes such that action attitude increases were related to reduced interference and increased activity only among patients at the action stage at pre-treatment; (c) pre- to mid-treatment decreases in depression did not account for these effects. Results suggest that any advantage enjoyed by patients with predominant action attitudes at pre-treatment may be enhanced by consolidating a pain self-management approach during treatment. In contrast, late-treatment gains of patients initially taking a predominant precontemplation stance were unaffected by their degree of early-treatment attitude changes.     

Initial development and validation of a multidimensional pain readiness to change questionnaire.

Psychometric instruments that assess patient readiness to adopt pain management skills taught in multidisciplinary pain management programs have the potential to clarify interindividual responses to treatment. To date, however, such questionnaires have examined overall readiness to self-manage pain in general rather than readiness to adopt the various specific skills that are taught in multidisciplinary pain treatment. The present study describes the initial construction and evaluation of a Multidimensional Pain Readiness to Change Questionnaire (MPRCQ) that measures readiness to adopt adaptive and avoid maladaptive pain coping strategies. The MPRCQ was initially administered to patients with fibromyalgia syndrome (n = 93) and then to a replication sample of persons with acquired amputations and spinal cord injuries who have chronic pain (n = 88). The results provide preliminary support for the reliability and validity of this instrument. Further research is needed to clarify the construct validity of the MPRCQ and its clinical utility.     

Identification of subgroups of persons with chronic pain based on profiles on the pain stages of change questionnaire

This study sought to identify reliable subgroups of patients with chronic pain based on profiles of subscale scores on the Pain Stages of Change Questionnaire (PSOCQ), a reliable and valid measure of individuals' readiness to adopt a self-management approach to chronic pain. The PSOCQ was administered to 633 people seeking treatment for chronic pain. Participants were predominantly White, averaged 48 years of age, about half were men, and about half reported back pain as the primary complaint. In a first study, cluster analysis was applied to 250 respondents. Five clusters were identified and named Precontemplation (11.0% of the sample), Contemplation (18.0%), Noncontemplative Action (12.4%), Participation (25%), and Ambivalent (33.6%). Results of a discriminant function analysis (DFA) on this sample, using the solution from the cluster analysis yielded a total error rate of 0.036. In a second study, the results of the first DFA were applied to an independent sample of 383 respondents in order to cross validate the solution from the first study. Cluster assignment proportions were very similar to the first sample and the posterior probability error rate for the second DFA was 13%. As predicted, clusters did not differ on measures of pain, disability, or demographics. Moreover, clusters differed significantly in theoretically consistent directions by scores on the Survey of Pain Attitudes, thus demonstrating criterion related validity for the clusters. Future research should examine the utility of PSOCQ profiles, relative to individual PSOCQ scale scores alone, in predicting response to self-management treatment approaches.     

A critical review of the pain readiness to change model.

Current approaches to treating chronic pain often incorporate a multidisciplinary approach and a focus on self-management. Although many of the patients who complete this type of treatment exhibit gains, there remain a significant proportion of patients who fail to engage in or complete this type of approach or who fail to adhere to treatment recommendations. In an attempt to address these issues, the construct of readiness (or motivation) to adopt a self-management approach to chronic pain has been described and has attracted research interest in recent years. Operationalization of the construct has led to the development of the Pain Stages of Change Questionnaire and other strategies for its assessment. Considerable discussion, debate, and ongoing research have expanded our understanding of motivation in the context of chronic pain treatment and have informed the articulation of potentially important ways in which self-management treatment approaches to chronic pain might be improved. The aim of this article is to review the work in this area and discuss implications for clinical practice and further research. PERSPECTIVE: This article reviews the research to date in the area of pain readiness to change. It provides readers with an overview of the current conceptualization of readiness and discusses important implications for multidisciplinary treatment interventions with a focus on self-management.     

How chronic pain patients cope with pain: Relation to treatment outcome in a multidisciplinary pain clinic

One hundred male and 100 female chronic pain patients in a multidisciplinary pain clinic completed a 34-item Pain Coping Questionnaire (PCQ). Factor analysis identified four pain coping factors: self-management, helplessness, social support, and medical remedies. Multiple-regression analyses were conducted to determine the relation between PCQ factors and measures of adjustment at admission to the pain program as well as admission to discharge changes in adjustment measures. The following concepts relevant to coping with chronic pain were defined: cognitive strategies, self-efficacy, helplessness, catastrophizing, and cognitive distortion. Suggestions were made for integrating these concepts in the development of scales for assessing strategies for coping with chronic pain.     

Readiness to adopt a self-management approach to pain: evaluation of the pain stages of change model in a non-pain-clinic sample

The Transtheoretical model of stages of behaviour change has stimulated research interest in relation to chronic pain, yet studies using the Pain Stages of Change Questionnaire (PSOCQ; Pain (72) 1997 227) have reported inconsistent findings and have generally utilized pain-clinic samples. The aims of the current study were to assess the general validity of the PSOCQ with a non-pain-clinic sample of patients with chronic pain, and to examine the utility of the stages of change model as applied to this population. The study employed multi-stage, cluster-sampling methodology, with 90 participants recruited from 19 medical and allied health clinics and practices. The findings demonstrated a number of limitations of the PSOCQ in terms of its ability to classify individuals into specific stages of change. The stages of change model requires adaptation in order to be useful for treatment planning in a non-pain-clinic sample of patients with chronic pain.     

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.     

Further support for the pain stages of change model: suggestions for improved measurement.

Recent efforts to operationalize persons' readiness to adopt a self-management approach to chronic pain have met with promising, but somewhat limited, results. The current study describes the development and psychometric evaluation of a German version of Pain Stages of Change Questionnaire (PSOCQ). A new item pool was developed to attempt to improve in particular the discriminant validity of the scales and in order to obtain a shortened measure. The items were administered to 494 chronic pain patients who were split into two independent samples. Item- and factor-analysis performed on data from one half of the sample resulted in four scales: precontemplation, preparation, action, and maintenance. The scales of the new measure, called the "Freiburg Questionnaire-Stages of Chronic Pain Management (FQ-STAPM)", showed good indices of reliability, homogeneity, and discriminant validity. Both the concurrent and divergent validity indices and the relationships between scale scores and pain related variables proved to be consistent with the transtheoretical model. Confirmatory factor analysis using LISREL performed on the second half of the sample supported the goodness-of-fit of the structure model. Implications of these findings for future research exploring the relevance of the pain stages of change model are discussed.     

Die Bedeutung der Änderungsbereitschaft des Transtheoretischen Modells (TTM) für den Verlauf der Bewältigung chronischer Schmerzen

BACKGROUND: Motivation in the concept of the transtheoretical model (TTM) is the readiness to change attitudes and behaviour. According to this patients with chronic pain pass through different stages of change (precontemplation, preparation, action, maintenance) before they adopt a new behaviour (e.g. relaxation exercise). This study analyses the impact of readiness to change over the course of 3 months. METHODS: Different questionnaires [coping with pain, impairment of pain, self-efficacy expectations and the German version of the Pain Stages of Change Questionnaires (PSOCQ), the FF-STABS] were administered two times to 74 patients of a rehabilitation clinic. Statistical analysis of covariance (SAS PROC MIXED) was used to analyse the relevance of the stages of change for the course of coping with chronic pain. RESULTS AND CONCLUSIONS: The stages of preparation, action and maintenance show statistically significant interrelations with coping with chronic pain subscales, and precontemplation covaries significantly with impairments of pain. The data suggest the relevance of the "readiness to change" concept for the realization of appropriate coping with chronic pain.     

Further development of the multidimensional pain readiness to change questionnaire: the MPRCQ2.

This study describes further development of the Multidimensional Pain Readiness to Change Questionnaire (MPRCQ2), a measure of readiness to adopt a variety of pain management and coping strategies commonly taught in multidisciplinary treatment programs. Clinical samples were recruited from a Fibromyalgia Day Program (n = 139) and an Arthritis Day Program (n = 51) as well as 2 survey samples with pain resulting from either a spinal cord injury (n = 127) or an amputation (n = 120). The results indicate preliminary support for the reliability and validity of the MPRCQ2. The MPRCQ2 may be helpful in future research investigating the relationship between readiness to change pain-related coping and adoption of coping behaviors and adjustment to chronic pain. PERSPECTIVE: This study describes the development of a revised version of the MPRCQ, the MPRCQ2, in 4 patient samples. The results support the reliability and validity of the MPRCQ2 in individuals with fibromyalgia syndrome, arthritis, acquired amputation, and spinal cord injury and improve on some aspects of the instrument.     

Higher levels of pain readiness to change and more positive affect reduce pain reports--a weekly assessment study on arthritis patients

The objective of the study was to analyze the relationships between Pain Readiness to Change, weekly measures of positive and negative affect and pain over eight subsequent weeks in patients with rheumatoid arthritis (RA). Factor analysis based on data from three different samples of patients with rheumatic diseases and other chronic pain conditions suggested a three factor solution for the Norwegian version of the Pain Stages of Change questionnaire (PSOCQ) representing Precontemplation, Contemplation, and Action/Maintenance (ACT) stages from the original Transtheoretical Model. Multilevel analyses on the weekly assessed data from a sub sample of 40 patients with RA revealed that higher levels of Pain Readiness to Change represented by high ACT scores were associated with more positive affect from week to week while no association was found between Readiness to Change and weekly pain. However, there was an interaction effect between Pain Readiness to Change and weekly positive affect on weekly pain, indicating that those persons having a higher level of Readiness to Change reported less pain in weeks when they also experienced increased positive affect. This may imply that a combination of cognitive factors and positive affect is most effective in relation to pain reduction. Results encourage continued investigation of apparent interactions between chronic pain, affect, and pain self-management.     

Outcome from integrated pain management treatment for recovering substance abusers.

There is little information on the efficacy of pain management for substance abusers with noncancerous chronic pain conditions. The present study describes an outcome evaluation of a pain management group adapted to the needs of patients diagnosed with concurrent chronic pain and substance abuse disorders. A heterogeneous group of 44 patients (66% opioid dependent; 61% musculoskeletal pain) attended a 10-week outpatient group based within a multidisciplinary substance abuse treatment program. Measures of addiction severity, pain, use of self-management techniques, emotional distress, medication use, and functional status were obtained at pretreatment, post-treatment, 3-month, and 12-month follow-ups. Outcome data were analyzed on the group and individual level, the latter using the reliable change index. Intention-to-treat analyses showed significant improvements in pain, emotional distress, medication reduction, and coping style. Half of the patients showed a statistically reliable improvement on at least 1 outcome measure, and half were opioid free at the 12-month follow-up assessment. These results suggest that persons with concurrent chronic pain and substance use disorders are responsive to an integrated treatment model of pain management and relapse prevention.