The Psychological Inflexibility in Pain Scale (PIPS) – Statistical properties and model fit of an instrument to assess change processes in pain related disability

Recent developments within CBT have emphasized acceptance rather than control of pain and distress in treatments aimed at improving functioning and life quality, but there is still a lack of reliable and valid instruments to assess relevant processes in such interventions. The Psychological Inflexibility in Pain Scale (PIPS) was developed to assess target variables in exposure and acceptance oriented treatments. A preliminary validation study resulted in a two‐factor solution with subscales for avoidance and cognitive fusion related to pain, showing satisfactory psychometric properties. This study sought to evaluate the instrument with 611 participants with whiplash associated disorders. Exploratory and confirmatory factor analyses supported a two‐factor solution with 12 items which showed an acceptable model fit, adequate internal consistencies, and strong relations with criteria variables (e.g. disability and life satisfaction). The construct validity of the instrument was supported by high correlations with subscales from the Chronic Pain Acceptance Questionnaire (CPAQ) and the Tampa Scale of Kinesiophobia (TSK). Notably, hierarchical regression analyses illustrated that PIPS explained more variance than TSK in pain, disability, life satisfaction and depression. Furthermore, PIPS was found to mediate the relationship between e.g. pain and disability, suggesting the usefulness of PIPS as a process measure in treatments of people with chronic pain. Thus, it is argued that this 12‐item version of PIPS may be used to explore the importance of psychological in/flexibility in chronic pain and to analyse processes of change in exposure based interventions, as well as for clinicians in tailoring interventions for patients with chronic debilitating pain.     

Investigating acceptance in adjustment to chronic pain: Is acceptance broader than we thought?

Research on the role of acceptance in adjustment to persisting pain has been facilitated by the development of the Chronic Pain Acceptance Questionnaire (CPAQ). However, to date the CPAQ has been used to explore acceptance of pain without taking into account the likely contribution of other cognitive variables that have been shown to influence adjustment to persisting pain. This study examined the role of pain acceptance, as measured by the CPAQ, in accounting for adjustment to pain when controlling for the effects of other cognitive variables. The results indicated that while the Activity engagement subscale of the CPAQ was predictive of depression severity, neither of the CPAQ's two subscales was predictive of pain severity or physical disability. These findings differ from some reported previously and they suggest that the CPAQ, by itself, may not be sufficient to explain the processes of acceptance of pain and, hence, adjustment to pain. The findings also indicate that the Pain willingness subscale of the CPAQ is not robust and should be discarded. A broader approach to investigating acceptance of pain is proposed.     

Reliability and validity study of the Finnish version of the Chronic Pain Acceptance Questionnaire (CPAQ)

Purpose: Acceptance has been discovered to be successful in improving quality of life when adjusting to chronic pain. Instead of avoiding and controlling the pain, the goal is to confront the pain and to live a value directed life. Thus far, there has not been an instrument in Finnish to assess the acceptance of chronic pain. This study aimed at translating the Chronic Pain Acceptance Questionnaire-(CPAQ)-into Finnish and assessing its reliability and validity. Method: Eighty-one persons with different types of chronic pain responded to the CPAQ, the Beck Depression Inventory (BDI), RAND-36 and questions of sociodemographic and pain-related variables. Results: The responders’ ages varied from 16 to 83 years (mean = 48.5 years) and 63% of them were women. For 55% of the participants, the pain had lasted more than 4 years and 63% from the sample had chronic pain in the low back or lower extremities. In test-retest analysis, the interclass correlation coefficient (ICC ) values were good, 0.81–0.87. Internal consistency was very good (α = 0.86). There was no floor-ceiling effect in the Finnish version of CPAQ. Correlation was found between both subscales of the CPAQ and every domain of the RAND-36 (r = 0.23; 0.68) and the BDI (r = ?0.24; ?0.62). Education, age, pain avoidance, social support and pain intensity correlated with either one of the subscales or total CPAQ. CPAQ revealed no association between fear of pain and pain duration. Conclusions: In conclusion, the Finnish version of the CPAQ is a reliable and valid method for measuring chronic pain acceptance.

Implications for Rehabilitation

Chronic Pain Acceptance Questionnaire

• There has not been an instrument in Finnish to assess the acceptance of chronic pain.

• The Finnish version of the Chronic Pain Acceptance Questionnaire (CPAQ) is a reliable and valid method for measuring chronic pain acceptance.

• In physiotherapy, CPAQ can be a useful instrument collecting background information of the chronic pain patient and assessing when to consult a psychologist. In addition in long therapies assessing the enhanced acceptance can be monitored with CPAQ.

     

A comparison of the relative utility of coping and acceptance-based measures in a sample of chronic pain sufferers.

Previous research suggests that to define the problem of chronic pain as a problem of coping may not be as useful as framing it as a problem of acceptance for some patients. The coping approach may encourage, or at least permit, a somewhat inflexible agenda of pain reduction or control while the acceptance approach may allow a more flexible agenda of willingness to have pain in some circumstances where that serves the goal of better life functioning. The purpose of this study was to continue to examine the relative utility of concepts of coping and acceptance of pain. Two hundred and thirty consecutive patients seeking assessment from a pain management service were the participants in the study. Patients completed the Coping Strategies Questionnaire (CSQ) and the Chronic Pain Acceptance Questionnaire (CPAQ). A revised scoring method was used for the CSQ (to correct for technical limitations noted in the past) and recently developed subscales of the CPAQ were examined. Correlation results showed that the acceptance variables were reliably stronger predictors of distress and disability compared with coping variables. Regression analyses confirmed that, compared with coping variables, acceptance accounted larger unique increments in variance in measures of patient functioning regardless of whether the coping variables were given priority in the regression equations. Increasing data support the view that the pain management field may benefit from evolving toward incorporating a less control-oriented and more accommodating view of aversive private experiences in some circumstances.     

Acceptance of pain in adolescents with chronic pain: Validation of an adapted assessment instrument and preliminary correlation analyses

It is important to understand the processes that contribute to disability and distress in adolescents with chronic pain. For example, research has identified that when adolescents can positively adapt to the consequences of health condition, rather than attempt to change the condition itself, they also function better and experience less distress. This pattern of behavior is similar to what is referred to as “acceptance” of pain in the adult literature. Although acceptance is consistently associated with positive outcomes in adult studies, there has been less investigation of acceptance in adolescents. This study aimed to examine the reliability and validity of an adolescent‐adapted version of the Chronic Pain Acceptance Questionnaire (CPAQ‐A), and, using this instrument, to carry out a preliminary investigation of acceptance in adolescents with chronic pain. A sample of 122 highly disabled adolescents with chronic pain attending a specialty service completed the adapted CPAQ‐A. They also completed standardized measures of their pain and daily functioning. Results supported the reliability and validity of the CPAQ‐A. Correlation analyses showed that higher levels of acceptance were associated with lower levels of distress and disability, but not with lower pain intensity. Regression analyses were carried out to assess the independent contribution of acceptance after pain intensity and demographic variables were taken into account. In these analyses acceptance accounted for significant variance in disability, psychological distress, and developmental and family functioning. We discuss developmental aspects of acceptance in adolescents and clinical implications of these findings.     

Validation of the Chronic Pain Acceptance Questionnaire (CPAQ) in an Internet sample and development and preliminary validation of the CPAQ-8

This study investigated the psychometric properties of the Chronic Pain Acceptance Questionnaire (CPAQ) in a mixed chronic pain, Internet sample and sought to develop a valid and reliable short form. Questionnaires were completed by 428 respondents, comprising a sample accessed via the Internet (n = 319) and a sample who completed a paper and pencil version of the measures (n = 109). Using confirmatory factor analysis (CFA) the two-factor structure of the CPAQ in the Internet sample was supported, though a good model fit was only achieved following the removal of one item. The resultant 19 item CPAQ demonstrated good reliability and evidence of validity was obtained for this sample. Data from the Internet sample were used to derive an eight-item short form. The two four-item factors (activity engagement [AE] and pain willingness [PW]) were confirmed using CFA and found to be invariant across both samples with good scale reliability. Higher CPAQ-8 and subscale scores were correlated with less depression and anxiety, pain severity and pain interference, and fewer medical visits for pain. Using structural equation modelling both subscales were found to partially mediate the impact of pain severity on pain interference and emotional distress. In this model AE had stronger associations with outcomes while PW accounted for a small portion of the variance in pain interference and anxiety, but not depression. This study confirmed the two-factor structure of the CPAQ in a mixed chronic pain Internet sample and provides preliminary evidence for the psychometric soundness of the CPAQ-8.     

The Chronic Pain Acceptance Questionnaire: confirmatory factor analysis and identification of patient subgroups

Over the past decade, the importance of acceptance of chronic pain has been demonstrated. Acceptance has often been assessed using the 20-item, two-factor Chronic Pain Acceptance Questionnaire (CPAQ; McCracken, Vowles, Eccleston, Pain 2004;107:159-66). This two-factor model has been supported but awaits further confirmation. The present investigation sought to address this issue in two large samples of pain suffers. Exploratory factor analyses (N=333) examined a number of solutions, ranging from two to five factors. Evaluation indices provided clear support for a 20-item, two-factor solution. Confirmatory factor analyses, using the second sample (N=308), examined a number of models. Fit indices demonstrated that the model identified in the exploratory analyses had the best fit. Finally, a series of cluster analyses were performed using a combined sample (N=641). Results indicated three clusters: one with high scores on both subscales (n=146), one with low scores on both subscales (n=239), and one with discrepant scores that were high on the Activity Engagement subscale and low on the Pain Willingness subscale (n=286). Follow-up analyses indicated significant differences among the clusters across multiple measures of functioning. The cluster with low CPAQ scores reported more difficulties in comparison to the group with high scores, while the group with discrepant CPAQ scores generally reported difficulties that fell in between. These results provide further support for the 20-item, two-factor CPAQ and indicate that it is both theoretically and practically useful.     

Acceptance of chronic pain: component analysis and a revised assessment method

Acceptance of chronic pain entails that an individual reduce unsuccessful attempts to avoid or control pain and focus instead on participation in valued activities and the pursuit of personally relevant goals. Recent research suggests that pain-related acceptance leads to enhanced emotional and physical functioning in chronic pain patients above and beyond the influence of depression, pain intensity, and coping. In these studies, acceptance was measured using the Chronic Pain Acceptance Questionnaire (CPAQ). Preliminary analyses of the CPAQ have supported its psychometric properties. The present study sought to further refine the CPAQ by examining its factor structure and evaluating the relations of these factors to other indices of pain-related distress and disability. Although a previously demonstrated factor structure of the CPAQ was generally supported, only factors assessing (a) the degree to which one engaged in life activities regardless of the pain and (b) willingness to experience pain had adequate reliability and validity and were significantly related to the other measures of patient functioning. A revised version of the CPAQ is suggested.     

Validation of the Chronic Pain Acceptance Questionnaire (CPAQ) in Cantonese-Speaking Chinese Patients

Acceptance of chronic pain has become an important concept in understanding and predicting that chronic pain sufferers can remain engaged with meaningful aspects of life. Assessment of acceptance has been facilitated by the development of Chronic Pain Acceptance Questionnaire (CPAQ). In this study, we aimed to test the reliability and validity of translated Chinese version of CPAQ to use this important tool in the future management of Hong Kong Chinese patients with chronic nonmalignant pain. Content validity was established by consensus formed among a panel of 5 experts in clinical psychology and pain specialty during the process of forward and backward translations. Test-retest reliability was examined by completing the Chinese CPAQ twice, 2 weeks apart, by 54 patients. A total of 224 Chinese patients with chronic nonmalignant pain attending our cluster multidisciplinary pain clinic were asked to complete a battery of psychometric instruments in Chinese, including an intake form for demographic data, Hospital Anxiety and Depression Score (HADS), Medical Outcome Study Short Form 36 (SF-36), Pain Catastrophizing Scale (PCS), and Pain Self-Efficacy Questionnaire (PSEQ). Analysis results showed that Chinese CPAQ had good test-retest reliability (intraclass correlation coefficient, 0.79) and internal consistency reliability (Cronbach α = 0.79). The Chinese CPAQ score was significantly correlated to anxiety, depression, pain catastrophizing, pain self-efficacy, and physical and psychosocial disability. Scree plot and Principal Components Factor analysis confirmed the same 2-factor construct as the original English CPAQ. Construct validity of the Chinese CPAQ can therefore be supported. In conclusion, the Chinese CPAQ is a reliable clinical assessment tool with valid construct for acceptance measurement in our heterogeneous Chinese patients sample with chronic nonmalignant pain.

Perspective

This article confirms the reliability and validity of a Chinese version of the CPAQ. The Chinese CPAQ can then be used by pain clinicians caring for Chinese chronic pain patients worldwide for acceptance-based psychometric assessment as well as therapies.     

Do quality of life,anxiety, depression and acceptance improve after interdisciplinary pain rehabilitation? A multicentre matched control study of acceptance and commitment therapy-based versus cognitive–behavioural therapy-based programmes

ObjectiveInterdisciplinary pain rehabilitation (IPR) usually employs a cognitive–behavioural therapeutic (CBT) approach. However, there is growing support for chronic pain treatments based on acceptance and commitment therapy (ACT). Most studies of ACT and CBT for chronic pain have evaluated their effects after psychological interventions, not after IPR. We compared the results of an ACT-based IPR programme with two CBT-based IPR programmes.MethodsWe used a retrospective multicentre pretest–posttest design with matched patient groups at three centres. Data were collected from the Swedish Quality Registry for Pain Rehabilitation before and after IPR participation. Participants completed the EQ-5D health-related quality of life questionnaire, the Chronic Pain Acceptance Questionnaire, (CPAQ) and the Hospital Anxiety and Depression Scale (HADS). Analyses were performed to compare the effects of the different interventions.ResultsNeither EQ-5D nor HADS depression scores were affected by the psychological approach used. The score changes on both CPAQ subscales (activity engagement and pain willingness) indicated significant improvements between admission and discharge at all centres.ConclusionsThese findings indicate the effectiveness of using psychological approaches to manage chronic pain. Both CBT and ACT had a beneficial effect on most of the assessed health-related parameters.     

Psychometric properties of Chronic Pain Acceptance Questionnaires: A systematic review

BackgroundTheoretically, acceptance of chronic pain (CP) is an important determinant in the functional status and well-being of patients with CP. Several questionnaires that aim to measure acceptance of CP have been developed. An overview of the psychometric properties of these questionnaires is unavailable.MethodsA systematic review of the literature of the psychometric properties of questionnaires that aim to measure acceptance of CP was performed. Psychometric properties including content construct and criterion validity, internal consistency. agreement, reliability, responsiveness, floor/ceiling effects and interpretability, were assessed using a standardized protocol. All studies were assessed by two observers independent from each other.ResultsA total of 23 studies including 4 questionnaires or subscales were identified. The questionnaires/subscales included were the Chronic Pain Acceptance Questionnaire (CPAQ), Illness Cognitions Questionnaire (ICQ), Pain Solutions Questionnaire (PASOL) and Acceptance of Illness Scale (AIS) adapted to pain. When applying the criteria of the protocol, results indicate that none of the questionnaires are currently able to meet all 9 criteria for psychometric quality. Individual questionnaires met between 0 and 3 of the criteria.ConclusionsIf strict psychometric quality criteria are applied, none of the questionnaires are currently able to meet all nine criteria for psychometric quality, but overlooking the cumulative results over all the studies conducted, especially for the CPAQ, it can be concluded that information on several important characteristics has been reported and a fairly clear picture emerges about the psychometric properties of the CPAQ.     

Chronic pain acceptance and affective well‐being: A coping perspective

This study examined the relationship between chronic pain acceptance and affective well‐being from a coping perspective. One hundred‐fifty patients from a multidisciplinary pain centre provided self‐report data including measures of pain acceptance, positive and negative affect, and accommodative flexibility. The bivariate and multiple correlation patterns were consistent with the assumption that pain willingness (the attitudinal component of pain acceptance including the recognition of the uncontrollability of pain) primarily reduces negative affect, whereas activity engagement (the behavioural component of pain acceptance including the pursuit of life activities despite pain) additionally produces positive affect. The data furthermore suggested activity engagement as a mediating link between pain willingness and positive affect. Moderation analyses showed that accommodative flexibility (the general readiness to adjust personal goals to situational constraints) facilitates both pain willingness and activity engagement – especially when average pain intensity is high. In sum, the results support the view that chronic pain patients’ well‐being is closely tied to the maintenance of life activities which presupposes an accepting attitude towards pain.     

The Tampa Scale for Kinesiophobia: further examination of psychometric properties in patients with chronic low back pain and fibromyalgia.

The present study attempted to replicate the robustness of a two-factor model of the Tampa Scale for Kinesiophobia (TSK) in chronic low back pain (CLBP) patients and fibromyalgia patients, by means of confirmatory factor analysis. Construct and predictive validity of the TSK subscales were also examined. Results clearly indicated that a two-factor model fitted best in both pain samples. These two factors were labelled somatic focus, which reflects the belief in underlying and serious medical problems, and activity avoidance, which reflects the belief that activity may result in (re)injury or increased pain. Construct validity of the TSK and its subscales was supported by moderate correlation coefficients with self-report measures of pain-related fear, pain catastrophising, and disability, predominantly in patients with CLBP. Predictive validity was supported by moderate correlation coefficients with performance on physical performance tests (i.e., lifting tasks, bicycle task) mainly in CLBP patients. Implications of the results are discussed and directions for future research are provided.     

Avoidance and cognitive fusion – Central components in pain related disability? Development and preliminary validation of the Psychological Inflexibility in Pain Scale (PIPS)

Acceptance of pain and other associated negative private experiences has received increasing attention in recent years. This approach is in stark contrast to the traditional approach of reducing or controlling symptoms of pain. The empirical support for treatments emphasizing exposure and acceptance, such as Acceptance and Commitment Therapy, is growing. However, to date, few instruments exist to assess the core processes in these types of treatments. This study describes the development and preliminary validation of the Psychological Inflexibility in Pain Scale. Principal components analysis (PCA) suggests a 2‐factor solution with a total of 16 items measuring avoidance of pain and cognitive fusion with pain. Results also indicate adequate reliability and validity for the scale. Implications of these findings for clinical assessment, as well as for research on pain related disability, are discussed along with suggestions for further research in this area.     

Psychological flexibility as a mediator of improvement in Acceptance and Commitment Therapy for patients with chronic pain following whiplash

Cognitive behavior therapy (CBT) has made important contributions to chronic pain management, but the process by which it is effective is not clear. Recently, strong arguments have been raised concerning the need for theory driven research to e.g. identify mechanisms of change in CBT and enhance the effectiveness of this type of treatment. However, the number of studies addressing these issues is still relatively scarce. Furthermore, the arrival of varieties of CBT with seemingly different process targets increases the need for such information. The present study explored the processes of change in a previously reported successful randomized controlled trial evaluating the effectiveness of an exposure‐based form of behavioral and cognitive therapy, Acceptance and Commitment Therapy (ACT), on improvement in pain‐related disability and life satisfaction for patients suffering from whiplash‐associated disorder (WAD). Several process variables relevant to theories underlying traditional CBT were included: pain, distress, kinesiophobia, self‐efficacy, and the process primarily targeted by ACT: psychological inflexibility. Mediation analyses were performed using a non‐parametric cross‐product of the coefficients approach. Results illustrated that pain intensity, anxiety, depression, kinesiophobia, and self‐efficacy did not have significant mediating effects on the dependent variables. In contrast, significant indirect effects were seen for psychological inflexibility on pain‐related disability (pre‐ to post‐change scores) and life satisfaction (pre‐ to post; pre‐ to 4‐month follow‐up change scores). Although tentative, these results support the mediating role of psychological inflexibility in ACT‐oriented interventions aimed at improving functioning and life satisfaction in people with chronic pain.     

Schmerzakzeptanz – Konzept und Überprüfung einer deutschen Fassung des Chronic Pain Acceptance Questionnaire

Background

Up to now, only an English version of the Chronic Pain Acceptance Questionnaire (CPAQ) has been available for measuring the acceptance of chronic pain. This paper presents and analyzes a German adaptation of this instrument.

Methods

The German scale was tested on 150 patients at the DRK Pain Center in Mainz. Validity was assessed by means of various indicators of pain and psychosocial impairment. In a subgroup (n=50) the association with the heat pain threshold was determined.

Results

The factor structure of the German CPAQ scale is largely concordant with the theoretical model. The internal consistency of the total and subscales is 0.84–0.87 (Cronbach’s alpha). The factors are closely related to indicators of psychosocial functioning. Associations with the affective dimension of pain are moderate and with the sensory dimension low. No association is found with heat pain thresholds (thermal sensory analyzer).

Conclusions

The German CPAQ scale is a useful German-language instrument for the measurement of acceptance and shows good psychometric properties. The study confirms that acceptance is not an expression of a physiologically based indolence.     

General psychological acceptance and chronic pain: There is more to accept than the pain itself

An increasing body of research demonstrates that acceptance of pain is significantly associated with the quality of daily functioning in people with chronic pain. The aim of the present study was to examine acceptance more broadly in relation to a wider range of undesirable experiences these people may encounter, such as other physical symptoms, experiences of emotional distress, or distressing thoughts. One hundred forty‐four, consecutive, adult patients attending interdisciplinary treatment for chronic pain participated in this study. They completed the Acceptance and Action Questionnaire‐II (AAQ‐II [Bond F, Hayes SC, Baer RA, Carpenter KM, Orcutt HK, Waltz T, Zettle RD. Preliminary psychometric properties of the Acceptance Action Questionnaire‐II: a revised measure of psychological flexibility and acceptance, submitted for publication]), measuring their general psychological acceptance. They also completed measures of emotional, physical, and psychosocial functioning, pain acceptance, and mindfulness. The AAQ‐II achieved satisfactory internal consistency, α = .89, and factor analysis revealed a unitary factor structure. Primary results showed that general psychological acceptance significantly correlated with depression, r = −.69, pain‐related anxiety, r = −.59, physical disability, r = −.42, and psychosocial disability, r = −.65, all p < .001. Hierarchical regression analyses showed that general psychological acceptance added a significant increment of explained variance to the prediction of patient functioning, independent of patient background characteristics, pain, acceptance of pain, and mindfulness. These results suggest that, when people with chronic pain are willing to have undesirable psychological experiences without attempting to control them, they may function better and suffer less. General acceptance may have a unique role to play in the disability and suffering of chronic pain beyond similar processes such as acceptance of pain or mindfulness.     

Acceptance of pain is an independent predictor of mental well-being in patients with chronic pain: empirical evidence and reappraisal

This paper reports upon: (1) the value of acceptance of pain in predicting well-being in patients suffering from chronic pain and (2) the construct validity of acceptance by comparing two questionnaires designed to measure acceptance (the Chronic Pain Acceptance Questionnaire, CPAQ, unpublished doctoral dissertation, University of Nevada, Reno, NV, 1992 and the Illness Cognitions Questionnaire, ICQ, J Consult Clin Psychol 69 (2001) 1026). The results of two independent cross-sectional studies are reported. Study 1 included 120 patients seeking help in tertiary care settings. In Study 2, 66 patients were recruited from a self-support group for fibromyalgia patients and from a pain clinic. Both studies revealed that acceptance of pain predicted mental well-being beyond pain severity and pain catastrophizing, but did not account for physical functioning. In both instruments, it was found that acceptance of pain was strongly related to engagement in normal life activities and the recognition that pain may not change. Acceptance in both instruments was strongly related to a cognitive control over pain. Study 2 further revealed that the correlation between the CPAQ and the ICQ is moderate, indicating that both instruments measured different aspects of acceptance. It is concluded that acceptance of chronic pain is best conceived of as the shift away from pain to non-pain aspects of life, and the shift away from a search for a cure with an acknowledgement that pain may not change.     

Fear of movement and (re)injury in chronic musculoskeletal pain: Evidence for an invariant two-factor model of the Tampa Scale for Kinesiophobia across pain diagnoses and Dutch, Swedish, and Canadian samples

The aims of the current study were twofold. First, the factor structure, reliability (i.e., internal consistency), and validity (i.e., concurrent criterion validity) of the Tampa Scale for Kinesiophobia (TSK), a measure of fear of movement and (re)injury, were investigated in a Dutch sample of patients with work-related upper extremity disorders (study 1). More specifically, examination of the factor structure involved a test of three competitive models: the one-factor model of all 17 TSK items, a one-factor model of the TSK (Woby SR, Roach NK, Urmston M, Watson P. Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain 2005;117:137-44.), and a two-factor model of the TSK-11. Second, invariance of the aforementioned TSK models was examined in patients with chronic musculoskeletal pain conditions (i.e., work-related upper extremity disorders, chronic low back pain, fibromyalgia, osteoarthritis) from The Netherlands, Sweden, and Canada was assessed (study 2). Results from study 1 showed that the two-factor model of the TSK-11 consisting of 'somatic focus' (TSK-SF) and 'activity avoidance' (TSK-AA) had the best fit. The TSK factors showed reasonable internal consistency, and were modestly but significantly related to disability, supporting the concurrent criterion validity of the TSK scales. Results from study 2 showed that the two-factor model of the TSK-11 was invariant across pain diagnoses and Dutch, Swedish, and Canadian samples. Altogether, we consider the TSK-11 and its two subscales a psychometrically sound instrument of fear of movement and (re)injury and recommend to use this measure in future research as well as in clinical settings.     

An assessment of the relative influence of pain coping, negative thoughts about pain, and pain acceptance on health-related quality of life among people with hemophilia

Many people with hemophilia are affected by chronic arthritic joint pain as well as acute bleeding pain. In this cross-sectional study, 209 men with hemophilia A or B completed the Hemophilia Pain Coping Questionnaire (HPCQ), the Chronic Pain Acceptance Questionnaire (CPAQ), and the RAND 36-item Health Survey (SF-36), a measure of health-related quality of life. Multiple regression was used to test the influence of active pain coping, passive adherence coping, and negative thoughts about pain (HPCQ scales), and activity engagement and pain willingness (CPAQ scales), on physical and mental components of quality of life (SF-36 PCS and MCS scales), taking account of age, hemophilia severity, use of clotting factor, and pain intensity. Pain intensity had the main influence on physical quality of life and negative thoughts had the main influence on mental quality of life. Activity engagement and pain willingness had small but significant influences on physical and mental quality of life. Pain willingness also moderated and partly mediated the influence of pain intensity on physical quality of life, and activity engagement and pain willingness mediated the influence of negative thoughts on mental quality of life. Negative thoughts moderated and partly mediated the influence of pain intensity on mental quality of life. There was no evidence that active pain coping influenced quality of life. The findings suggest that quality of life in hemophilia could potentially be improved by interventions to increase pain acceptance and reduce negative thoughts about pain.