The chronic pain coping inventory: development and preliminary validation

Pain, 60 (1995) 203-216 203 © 1995 Elsevier Science B.V. All rights reserved 0304-3959/95/$09.50

PAIN 2642

The Chronic Pain Coping Inventory: development and preliminary validation

Mark P. Jensen a,c,* Judith A. Turner a,b,c Joan M. Romano b,c and Susan E. Strom c

Departments of ~ Rehabilitation Medicine (RJ-30) and ~ Psychiatry and Behauioral Sciences (RP-IO), Unil,ersity of Washington School of Medicine, Seattle, WA 98195 (USA)

" Multidisciplinary Pain Center (RC-95), Uniuersity of Washington Medical Center, Seattle, WA 98195 (USA)

(Received 1 February 1994, revision received 3 May 1994, accepted 13 May 1994)

Summary This paper describes the development and validation of a measure of strategies used by patients to cope with chronic pain, the Chronic Pain Coping Inventory (CPCI). A 104-item measure of pain coping responses and 3 measures of functioning were completed by 176 chronic pain patients. Two-week retest data were provided by 111 of these patients. Item and scale analyses resulted in a 65-item measure that assessed 11 pain coping dimensions. This inventory was then cross-validated in a second sample of chronic pain patients (n = 78), who also completed a measure of pain-related distress. The significant others (typically, spouses) of patients in the second sample rated patients on a significant-other version of the CPCI and on other measures of patient functioning. The results support the reliability of the CPCI scales. Four scales (Guarding, Resting, Asking for Assistance, and Task Persistence) predicted patient- and significant other-reported patient adjustment. Eight scales (Guarding, Opioid Medication Use, NSAID Use, Sedative-Hypnotic Medication Use, Resting, Asking for Assistance, and Exercise/ Stretch) demonstrated moderate-to-strong relationships between patient and significant-other versions, further supporting their validity.

Key words: Chronic pain; Coping; Chronic Pain Coping Inventory

Introduction

Coping may be defined as the use of behavioral and cognitive techniques to manage stressful demands (Lazarus and Folkman 1984). Evidence from a number of sources suggests that differences in the use of pain coping strategies may play a significant role in adjustment to chronic pain (Jensen et al. 1991b, Turner 1991; Keefe et al. 1992; Smith and Wallston 1992; Thompson et al. 1992). Correlational studies, for example, show that strategies such as positive self-statements, ignoring pain, and increasing activities are associated with better psychological functioning in chronic pain patients (Keefe and Williams 1990; Jensen and Karoly 1991,

* Corresponding author: Mark P. Jensen, Department of Rehabilita- tion Medicine (RJ-30), University of Washington School of Medicine, Seattle, WA 98195, USA. Tel.: (206) 543-3602; FAX: (206) 685-3244.

1992). Diverting attention from pain, ignoring pain, and the use of coping self-statements have been shown to be associated with better physical functioning (Jen- sen and Karoly 1991), and the use of rest to cope with pain appears to be associated with worse physical functioning (Jensen et al. 1991b).

Further evidence for the potential importance of coping comes from controlled treatment outcome studies which demonstrate that interventions designed to change patient coping improve functioning among chronic pain patients. Chronic pain patients who re- ceive relaxation training report greater decreases in pain (Nouwen and Solinger 1979; Turner 1982; Flor et al. 1986), decreases in psychological distress (Turner 1982; Flor et al. 1986), and decreases in functional disability (Turner 1982; Flor et al. 1986) than do patients in waiting-list or attention-placebo control condi- tions. Chronic pain patients who participate in cognitive therapy designed to alter their self-talk also report decreases in pain intensity (Rybstein-Blinchik 1979;

SSDI 0 3 0 4 - 3 9 5 9 ( 9 4 ) 0 0 1 1 8 - X

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Turner 1982; Spence 1989), distress (Turner 1982; Spence 1989), and disability (Turner 1982; Puder 1988; Spence 1989) relative to waiting-list or attention- placebo control groups. Similarly, osteoarthritic knee pain patients taught a variety of pain coping strategies (such as relaxation, imagery, distraction, activity-rest cycling, pleasant activity scheduling, and cognitive re- structuring) report significantly less pain and psychological disability post-treatment than do patients re- ceiving education about arthritis or standard care (Keefe et al. 1990a). Adding cognitive therapy to a physical therapy program has also been shown to boost the effectiveness of physical therapy (Nicholas et al. 1991).

However, there are several unanswered questions regarding the relationship of coping to functioning among chronic pain patients (Jensen et al. 1991b). For example, although pain coping strategy measures have been developed (Rosenstiel and Keefe 1983; Brown and Nicassio 1987), there is no standardized measure that includes a number of the specific behavioral coping strategies that are targets of change in multidisciplinary pain programs. These strategies include ones that tend to be encouraged (e.g., exercise, muscle stretching, task persistence, and relaxation) as well as strategies that generally are discouraged (e.g., the use of guarding, resting, and asking for assistance).

A measure that assesses the use of behavioral pain coping strategies could serve many purposes. First, such a measure may be used to determine if concurrent relationships exist between the use of these strategies and functioning among chronic pain patients. The lack of significant concurrent relationships may indicate that these coping strategies have no effect on adjustment, and therefore are less important to emphasize in treatment. Second, a measure of these coping strategies is necessary to determine if treatment is effective in altering their use, and if pre- to post-treatment changes in coping strategy use are maintained at follow-up. Third, a measure of coping strategies specifically targeted in treatment may be used to study whether changes in coping strategies are associated with treatment outcome. Finally, such a measure might, alone or in combination with other measures, be used to identify subgroups of patients for whom coping strategy modification might be particularly important. The purpose of this paper is to describe the development and preliminary validation of a new measure of pain coping that incorporates the behavioral pain coping strategies of guarding, resting, asking for assistance. medication use, relaxation, task persistence, exercise. and stretching. We elected to include an additional coping strategy that is not typically encouraged or discouraged in treatment, seeking social support, because of the large body of evidence that indicates such a strategy is related to functioning among patient pop-

ulations in general (cf., Broadhead et al. 1983) and chronic pain patients in particular (Brown et al. 1989; Turk et al. 1992).

Development and preliminary validation of the scale

Methods

Item writing Three of the authors (M.P.J., J.A.T., J.M.R.) developed a com-

prehensive list of pain coping strategies that included strategies specifically emphasized in the University of Washington Multidisci- p!inary Pain Treatment Program, as well as those deemed important by researchers and clinicians in the pain and coping literature. We categorized coping strategies into 3 types, based on whether they were (1) wellness-focussed and encouraged in treatment. (2) illness- focussed and discouraged in treatment, or (3) neither (i.e., not encouraged or discouraged), according to current multidisciplinary treatment practice (Loeser et at. 1990).

A paragraph description of each coping strategy was prepared and used to construct specific questionnaire items exemplifying these strategies. 2 In writing the items, we sought to avoid complex sen- tence structure, double negatives, passive voice, and ambiguous wording, initially, 103 items were written to assess 14 behavioral and cognitive pain coping efforts (guarding, resting, counter-stimulation, professional services utilization, asking for assistance, relaxation, task persistence, stretching, exercising, reinterpreting pain, ignoring pain, coping self-statements, seeking social support, and seeking information). To assess medication use as a coping behavior, an additional item asked patients to list all medications taken for pain and the frequency with which they are used. Listed medications are coded as opioids, non-steroidal anti-inflammatory drugs (NSAIDS), or sedative-hypnotics. Opioids include any drug containing a natural or synthetic opiate derivative. Similarly, any single or combination drug containing a sedative or hypnotic substance (including benzodiazap- ines) is coded as a sedative-hypnotic. Drugs that contain both opiates and sedative-hypnotics are coded as both. NSAIDS include prescription and non-prescription medications containing NSAIDS without opioid or sedative-hypnotic compounds. Other medications and drugs are not coded. More specific information concerning how medication use was coded is presented in the scoring instructions (see Appendix liD.

Several factors were considered in the selection of the response tormat for the coping items. Stone et al. (1991) have pointed out that [he response format used in many coping measures are not very specific (e.g., 'used strategy some of the time' to 'used strategy all of the time'). Non-specific responses can be interpreted differently by respondents, making meaningful comparisons between subjects diffi- cult. In the development of the current coping measure, we considered asking subjects to indicate the specific number of times they

Recommendat ions regarding the use of specific coping strategies, in practice, vary somewhat from patient to patient. For example, patients who have a tendency to 'overdo' may be encouraged to alternate periods of activity with rest, and some patients are given the recommendation to use anti-inflammatory medications as a part of their overall pain management plan. However, in general, chronic pain patients are encouraged to use the wellness-focussed strategies and discouraged from using the illness-focussed ones. This issue will be addressed further in the Discussion.

-' Paragraph descriptions of each coping dimension are available from the first author.

used a coping strategy during the past week. Although this met the desired specificity criteria, we also believed that subjects would be unable to recall accurately the exact number of times they used specific strategies over the course of a week. We elected to use the number of days a strategy was used during the past week as the response option for the coping items in order to maximize the meaningfulness and comparability of responses across subjects and minimize difficulty of the recall task.

Subjects The questionnaire items were administered to a convenience

sample of 176 chronic pain patients who had been screened for possible treatment in the University of Washington Multidisciplinary Pain Program. The average age of the study participants was 47.43 years (SD: 13.87 years; range: 18-91 years), and the median duration of pain was 5.5 years (range: 3 months to 59 years). Of the subjects 57% were women; 68% were married or living with a significant other. The rest reported that they were divorced (14%), had never been married (11%), were separated from their spouse (1%), or were widowed (6%). Sixty-nine percent reported that they were not work- ing: 40% because of pain, 19% because of retirement, and 10% for other reasons. The majority of the subjects were Caucasian (92%). The rest reported their ethnic status to be African-American (1%), Asian (2%), Hispanic (1%), Native American (2%) or 'other' (2%). The most frequent primary sites of pain were the leg (26%) or the low back (25%). Other primary sites included head (15%), neck (7%), shoulder/arm (12%), abdomen (6%), upper back (6%), anal/ genital region (2%), and multiple primary sites (1%). Of these patients 94 (53%) had been treated in the Multidisciplinary Pain Program since they were initially screened.

Measures In addition to the chronic pain coping items, the study partici-

pants completed measures to assess 3 areas of functioning: depression, activity level, and distress associated with pain. Depression was assessed using the Center for Epidemiological Studies Depression Scale (CES-D) (Radloff 1977). The reliability and validity of the CES-D are well established, and the measure has been applied to research with chronic pain patients (cf., Brown 1990; Jensen and Karoly 1991; Romano et al. 1991). Activity level was assessed using the 4 activity subscales of the Multidimensional Pain Inventory (MPI) (Kerns et al. 1985). These scales assess frequency of perform- ing domestic activities, household chores, social activities, and recreational activities. Discriminant and convergent validity have been demonstrated for these subscales (Kerns et al. 1985). Distress associated with pain was assessed by the Pain Discomfort Scale (PDS) (Jensen et al. 1991a). The PDS consists of 10 items confirming or denying negative emotional responses associated with pain (e.g., fear, unpleasantness, enjoyment of life, annoyance). Internal consistency (alpha coefficient = 0.77) and test-retest stability over a 3-month period (correlation coefficient = 0.76) are both satisfactory for the PDS (Jensen et al. 1991a). Also, previous results support the discriminant validity of the PDS in differentiating distress attributed to pain from depression (Jensen et al. 1991a).

Procedure Pain Center staff mailed invitation letters and informed consent

forms to all patients who had been screened for possible inpatient multidisciplinary pain treatment at the University of Washington Pain Center for the 2 years prior to the initiation of data collection, and for whom current addresses were available (n = 982). Of these, we learned that 4 were deceased, 11 wrote to state that they were unwilling to participate, 67 letters were returned with no known forwarding address, and 216 returned signed consent forms and were mailed the Chronic Pain Coping Inventory (CPCI) items, as well as the measures of depression, activity level, and distress. Completed

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measures were obtained from 176 of these patients. Patients who returned completed measures were mailed the coping items again 2 weeks after they returned the initial packet. Requests for retest data were stopped when an adequate number of completed retest questionnaires (100) were returned. Eleven additional retest questionnaires arrived after mailed requests were stopped, making a total of 111 retest measures available.

Results

Item analyses Correlation coefficients were computed between

each of the 103 coping items and each of the 14 scale scores (scale score = the sum of the responses of the items associated with each scale). Individual items were retained if they had at least a moderate correlation (r = 0.40 or more) with the parent scale and if the correlation between the item and the parent scale was at least 0.15 greater than the correlation between that item and all the other scales. These analyses indicated that the items written for the exercise and stretch scales were closely associated with one another. They were therefore combined into a single index.

Scale analysis The internal consistencies (alpha coefficients) and

test-retest stabilities (correlation coefficients) of the scales resulting from the item analyses were then computed. Test-retest stability coefficients were also computed for the medication scores. Scales were retained if these measures of reliability was adequately high; that is, 0.70 or greater (Nunnally 1978). Five of the scales (Professional Services Utilization, Ignore Pain, Reinterpret Pain Sensations, Counter-Stimulation, and Seeking Information) did not meet the reliability criteria, and so were dropped from the measure. This initial item analysis left 58 items associated with 11 coping strategies; 57 items formed 8 coping scales, and responses to the 58th item concerning medications taken for pain were coded to form the 3 measures of medication use (Opioid, NSAID, and Sedative-Hypnotic Med- ication use) described above. The measure was titled the Chronic Pain Coping Inventory (CPCI). The internal consistencies (alpha coefficients) for the 8 scales ranged from 0.70 to 0.93 (median: 0.84). Test-retest stabilities for the 8 scales and 3 medication use measures ranged from 0.66 to 0.90 (median: 0.80). All stability coefficients but one (Non-steroidal Medication Use: r = 0.66) were 0.70 or greater.

Initial scale validation The correlation coefficients between the CPCI scale

scores and the 3 measures of adjustment (the CES-D, MPI Activity scale, and the PDS) are presented in Table I. Because of the large number of coefficients computed, the alpha level was set at 0.001 in order to control for type I error.

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TABLE 1

CORRELATION COEFFICIENTS BETWEEN THE INITIAL, (58-item) CPCI AND ADJUSTMENT MEASURES

CES-D, Center for Epidemiological Studies Depression Scale; PDS, Pain Discomfort Scale; MPI-A, Multidimensional Pain Inventory-Ac- tivity Scale

Scale CES-D PDS MPI-A

Illness-Focussed Coping Guarding 0.35 ~ 0.45 :+ ().36 :+: Resting 0.32 * 0.43 * -0.22 Asking for Assistance 0.14 0.29 * -I).22 Opioid Medication Use 0.12 0.19 0.14 Non-steroidal Medication Use -0 .10 -0 .05 0.(19 Sedative-Hypnotic Medication Use 0.14 (I.11 0.03

Wellness-Focussed Coping Relaxation 0.10 0.06 0. II Task Persistence -0 .24 * -0 .33 * 0.20 Exercise/Stretch - 0.14 - 0.16 0.()9 Coping Self-Statements (I.{)9 0.24 * {).01

Other Coping Seeking Social Support 0.06 0.15 0.21

* P < 0.001.

We anticipated that, in general, the illness-focussed scales would be associated positively with the measures of dysfunction (CES-D and PDS) and negatively with the measure of activity level (MPI Activity Total score). Wellness-focussed coping scores were predicted to show the opposite pattern. Of the 9 statistically significant relationships found, 8 (89%) were in the predicted direction (see Table I). The single Coping Strategy Scale score that was associated with adjustment in the direction opposite to that predicted was Coping Self- Statements; greater endorsement of this strategy was associated with a higher level of pain-associated distress.

Further development and cross-validation of the CPCI

Methods

Subjects The subjects for the second phase of scale development consisted

of 78 patients screened for treatment in the University of Washing- ton Multidisciplinary Pain Program, and their significant others. during a period of 26 weeks (from 6 April 1992 to 2 October 1992). All patients were asked to bring a significant other (usually a spouse or partner) to the evaluation, and they were eligible to participate in the study if both could read and write English.

The demographic characteristics of this group of patients were similar to that of the subjects in the initial scale development sample, with no significant differences found on gender distribution, employ- ment status, ethnic status, and primary pain site. The second sample of patients was, however, younger (mean age: 42.17 years, SD: 13.22 years vs. 47.43 years, SD - 13.87 years in the initial sample; t (253) = 2.82, P < 0.01) and more likely to be married (78% married or living with a significant other vs. 68% in the initial sample; ~2 (1, n = 254) - 4.31, P < 0.05).

Measures CPCl: patient and spouse l,ersions .Seven items were added to the

original CPC! to increase the number of items in the Resting and Seeking Social Support scales. Other than these additional items, the patient version was the same as the initial inventory. The CPCI is contained in Appendix I. A significant-other version of the measure was also developed (see Appendix II), and includes the following scales that assess behaviors observable by significant others: Guard- ing, Resting, Exercise/Stretch, Asking For Assistance, Task Persis- tence, Relaxation, and Medication Use (to be later coded as Opioids, NSA1DS, and Sedative-Hypnotics; see scoring instructions included in Appendix III). In addition, significant others were given the option of marking 'unable to observe' for those specific coping strategy items they believed that they did not have a chance to observe during the past week.

Roland Scale. As a measure of observed disability, significant others were asked to complete the Roland Scale (Roland and Morris 1983). The 24 items of the Roland Scale were derived from the Sickness Impact Profile (Bergner et al. 1981) specifically for the assessment of disability associated with back pain. Research has supported the reliability and validity of this scale for assessing dysfunction associated with pain in a variety of sites (Deyo 1986; Lanier and Stockton 1988; Jensen et al. 1992).

Acticity subscales ~fthe MPI. Significant others were also asked to complete the activity subscales (Domestic Activities, Household Chores. Social Activities, and Recreational Activities) of the MPI as an assessment of the observed level of patient activity (Kerns et al. 1985).

Pain-related distress. Distress associated with pain was assessed using the PDS (Jensen et al. 1991a), described above.

Procedu re Those patients and their significant others who expressed a

willingness to participate were asked to complete the measures described above at the time of their screening. Only significant others were asked to complete the measures of disability and activity level in order to reduce the assessment burden on the patient. Although patients and significant others were asked to try to complete the measures on the day of the patients' evaluations, they were allowed to complete the measures at home and return them by mail if necessary.

Results

CPCI scale reliabilities I n t e r n a l c o n s i s t e n c y ( a l p h a ) c o e f f i c i e n t s w e r e c a l c u -

l a t e d f o r b o t h t h e p a t i e n t a n d s i g n i f i c a n t - o t h e r v e r s i o n s

o f t h e C P C I . T h e s e r e s u l t s a r e p r e s e n t e d in T a b l e II .

A s c a n b e s e e n , e a c h o f t h e s c a l e s d e m o n s t r a t e d g o o d

( 0 . 7 4 - 0 . 7 9 ) o r e x c e l l e n t ( > 0 .80) i n t e r n a l c o n s i s t e n c y

c o e f f i c i e n t s f o r b o t h t h e p a t i e n t a n d t h e s i g n i f i c a n t -

o t h e r v e r s i o n s .

Agreement between patient and significant-other lTersions T o d e t e r m i n e t h e a g r e e m e n t b e t w e e n p a t i e n t a n d

s i g n i f i c a n t - o t h e r r a t i n g s o f p a t i e n t c o p i n g r e s p o n s e s ,

c o r r e l a t i o n c o e f f i c i e n t s b e t w e e n p a t i e n t s ' a n d t h e i r s ig-

n i f i c a n t o t h e r s ' r e p o r t s o f c o p i n g w e r e c o m p u t e d ( s e e

T a b l e II) . T h e r e s u l t s o f t h e s e a n a l y s e s i n d i c a t e s o m e

v a r i a b i l i t y in a g r e e m e n t b e t w e e n t h e p a t i e n t a n d s ign i f -

i c a n t - o t h e r v e r s i o n s . T h e h i g h e s t c o e f f i c i e n t s e m e r g e d

f o r G u a r d i n g , M e d i c a t i o n U s e , R e s t i n g , a n d E x e r c i s e /

TABLE II

INTERNAL CONSISTENCIES OF AND CORRELATIONS BE- TWEEN THE PATIENT AND SIGNIFICANT-OTHER VER- SIONS OF THE FINAL (65-item) CPCI SCALES

SO, significant other.

Scale Internal consistencies Patient-SO Patient SO correlation version version

Guarding 0.83 0.85 0.65 Resting 0.74 0.75 0.47 Asking for Assistance 0.87 0.84 0.31 Relaxation 0.83 0.79 0.13 Task Persistence 0.85 0.85 0.24 Exercise/Stretch 0.91 0.85 0.41 Seeking Social Support 0.86 0.87 0.29 Coping Self-Statements * 0.89 - - Opioid Medication Use ** - 0.55 Non-steroidal

Medication Use ** - - 0.57 Sedative-Hypnotic

Medication Use ** - - 0.65

* There is no significant other version of this scale. ** Because medication use scores are derived from

internal consistencies cannot be calculated. single items,

Stretch. Lower correlations emerged for the Asking For Assistance, Seeking Social Support, Task Persis- tence, and Relaxation scales.

Relationship between patient and significant-other versions and measures of adjustment

Table III lists the correlation coefficients between the patient and significant-other-completed versions of the CPCI and the 3 measures of functioning; the MPI Activity score and Roland Scale (both. completed by the significant other), and the PDS (completed by the patient). As before, because of the large number of correlations computed, the alpha level was set at 0.001 in order to control for type I error.

Three aspects of these correlations are relevant to conclusions about the validity of the CPCI scales. First, the relationships between the coping inventory scales and the adjustment measures are similar for the patient and significant-other versions of the CPCI. For every coefficient that reached statistical significance for the CPCI patient version (P < 0.001), the corresponding scale in the significant-other version was also significantly associated, or demonstrated a trend (P < 0.05) to be associated, with the same adjustment measure in the same direction (see Table Ili). Even among the coefficients that did not reach statistical significance, the magnitudes were remarkably similar for the patient and spouse versions. These results suggest that the pattern of relationships between the CPCI scores and functioning measures does not differ depending upon whether coping is assessed by self-report (patient ver-

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sion) or by observation (significant-other version). Sec- ond, all of the statistically significant relationships were in the predicted direction (i.e., illness-focussed coping scales were associated positively with dysfunction and negatively with activity level, and wellness-focussed coping scales showed the opposite pattern). More im- portantly, most of the significant relationships between measures of coping and functioning found in the preliminary validation study were replicated in the second study. Guarding, Resting, and Asking for Assistance were all associated positively with greater depression and pain-related distress, and Task Persistence was associated with higher activity level and less distress and depression. Several of the scales that were only weakly related to adjustment in the first study also tended to show weak relationships to adjustment in the second study. These included the scales that measured relaxation, exercising/stretching, and seeking social support.

Discussion

The focus of this study was the development and initial validation of a multiple-scale measure of chronic pain coping strategy use. Specifically, we sought to develop a measure that incorporated several pain coping strategies targeted for change in multidisciplinary treatment but not assessed by other measures. These included strategies that are encouraged in the multidisciplinary treatment of chronic pain (such as relaxation, task persistence, exercise, and stretch), and strategies that tend to be discouraged (such as pain-contingent rest, asking for assistance, guarding a body part, and medication use).

The results of this study indicate that the CPCI scales are reliable. All of the internal consistency coefficients were greater than 0.70, and the majority (80%) were greater than 0.80 for both the patient and significant-other versions of the measure. Moreover, the test-retest reliability coefficients were greater than 0.70 for all but one measure (Non-steroidal Medication Use: r = 0.66).

The scales of the CPCI demonstrated varying de- grees of association with measures of patient functioning. However, the magnitudes of the relationships found were consistent across samples and sources of coping information (i.e., patient vs. significant-other reported). Four of the scales, in particular, appeared to be most closely associated with functioning in both samples of patients (Guarding, Resting, Asking for Assistance, and Task Persistence).

Other strategies (Opioid Medication Use, NSAID Use, Sedative-Hypnotic Medication Use, Relaxation, Exercise/Stretch, Coping Self-Statements, and Seek- ing Social Support) demonstrated inconsistent or weak

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T A B L E I l l

C O R R E L A T I O N C O E F F I C I E N T S B E T W E E N T H E F I N A L (65 item) C P C I A N D 3 M E A S U R E S O F A D J U S T M E N T

The Roland and MPI-A scales were completed by the patients' significant o the r s . N o spouse version exists for the Coping Self-Statements scale. SO, significant other.

CPCI scale Patient-completed SO-completed

Pain Discomfort scale Roland scale MPI Activity level

Illness-Focussed Coping Guarding

Patient v e r s i o n

S O v e r s i o n

Resting Patient version S O v e r s i o n

Asking for Assistance Patient version S O v e r s i o n

Opioid Medication U s e

Patient version S O version

Non-steroidal Medication U s e

Patient version S O v e r s i o n

Sedative-Hypnotic Medication U s e

Patient version S O v e r s i o n

Wellness-Focussed Coping Relaxation


Task Persistence Patient version S O version

Exercise/Stretch Patient version S O version

Coping Self-Statements Patient version

Other Coping Seeking Social Support


0.15 (I.58 * 1/.25

(t.14 (I.67 * - 0 . 4 1 *

0.1(~ 0.50 * - 0 . 3 5 *

0.13 (I.51 * - 0 . 4 5 *

0.03 0.43 * - 0 . 2 1

0.09 0.57 * - 0.12

- 0.(16 0.23 - 0.18

-- 0.17 (I.(15 0.04

• (). 1~ 0.01 0.04

- 0.26 - 0.02 0.04

- 0.02 (I.34 * - 0.37 *

(I.04 0.35 - 0.32

0.09 0.21 0.09

- 0.01 0.22 0.07

- 0.33 * 0.22 0.12

- 0.43 ~ 0.38 * 0.23

0.1 I 0.10 0.05 - 0.08 0.05 0.16

- 0.15 0.26 - 0.17

0.03 [).29 - 0.08

0.07 0.06 0.29

* P < 0.001.

relationships to measures of functioning in two samples. There are several possible explanations for these findings. First, these coping strategies may be related to functioning, but not measured adequately by the CPCI. Second, these scales may be related to functioning, but not the specific measures of functioning used in this study. Third, the use of these coping strategies may not be associated with functioning in chronic pain patients. Finally, it remains possible that some of these coping strategies are related to the adjustment of some chronic pain patients, but not others, and that significant relationships are obscured by examining them in heterogeneous samples.

Another means of assessing the validity of the scales is to examine whether patient and significant other versions of the measure are associated. The results of

the present analyses support the validity of some scales over others using this criterion. Although, as predicted, all of the relationships were positive, strong relationships (i.e., correlation coefficients greater than 0.50, Cohen and Cohen 1983) were found only for Guarding, Opioid Medication Use, NSAID Use, and Sedative- Hypnotic Medication Use. Moderate relationships (0.30-0.49) were found for Resting, Asking for Assis- tance, Exercise/Stretch, and Counter-Stimulation. For the remaining 3 scales, Relaxation, Task Persistence, and Seeking Social Support, weak relationships emerged (0.10-0.29), suggesting that patients and their significant others do not always agree about the frequency with which patients use these strategies. One possible explanation is that there may be less opportunity for significant others to observe some of these

specific strategies, such as relaxation. It is also possible that there may be some inconsistency across individuals in how these strategies are defined. For example, a patient continuing to work at a task for 10 min after a pain flare-up may believe that he or she 'just kept going' (item 51, patient version), while an observer who sees the patient stop a task after 10 min may decide that the patient did not 'just keep going' (item 38, significant-other version) to cope with pain.

In future research, it would be worth exploring methods for dealing with the lack of high agreement between patients and significant others on some of the CPCI scales. One possible strategy might involve pro- viding more detailed definitions and examples of the coping strategies to patients and their significant others before completing the measure. A second strategy might be to use large discrepancies between subjects and significant others to exclude subjects from subse- quent analyses. Assuming that such an approach in- creases the validity of the measurements retained in the analyses, this strategy theoretically could result in a more valid indication of the true relationships between coping and outcome variables.

One of the problems that has been identified in the area of coping with chronic pain is the lack of objective measures of coping (Jensen et al. 1991b). The CPCI may be used by a significant other to rate the frequency of coping efforts for all but one of the strategies (Coping Self-Statements). The correlations between patient and significant other versions of the scales, and between significant-other versions of the scale and measures of functioning, provide preliminary support for the validity of significant-other versions of the following scales: Guarding, Resting, Asking for Assistance, Medication Use scales, and Task Persis- tence. The validity of the significant other versions of other scales (Relaxation, Exercise/Stretch, and Seek- ing Social Support) needs to be explored further.

A second problem associated with previous research using pain coping measures is the possibility of conceptual overlap between measures of coping and measures of functioning (Sullivan and D'Eon 1990; Jensen et al. 1991b; Keefe et al. 1992). For example, some cognitive responses to pain (as assessed by the Catastrophizing and Coping Self-Statements scales of the Coping Strat- egy Questionnaire (Rosenstiel and Keefe 1983) and the Coping Self-Statements scale of the CPCI) might re- flect the same underlying dimension tapped by measures of psychological functioning (such as measures of depression, cf., Sullivan and D'Eon 1990). The negative thoughts and paucity of positive self-statements that characterize many pain patients might be considered to be part of the symptomatology of psychological dysfunction, rather than purposeful efforts to manage pain and associated problems. Similarly, measures of behavioral coping strategies, such as the Increase Activities

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scale of the Coping Strategy Questionnaire and the majority of the CPCI scales, might tap into an underlying dimension of physical functioning. Moreover, variables such as medication use, resting in bed, engaging in a distracting activity such as going to the movies or shopping may be viewed as coping strategies by one investigator, and as outcome variables by another (Keefe et al. 1992). In using any pain coping measure, investigators need to consider carefully how to measure coping and outcome or functioning to ensure that these constructs are separated. One of the advantages of the CPCI is that it provides clinicians and researchers with more choice in the assessment of behavioral strategies that are taught for coping with pain. The more coping strategies that can be assessed (that have the potential to impact functioning), the more opportunity researchers have to select coping measures that have minimal conceptual overlap with outcome measures of interest.

A methodological strategy that may be used to deal with potential problems associated with conceptual overlap is to perform longitudinal studies, predicting change in functioning over time while controlling for initial level of functioning. This approach was em- ployed by Keefe et al. (1990b), who demonstrated that initial Catastrophizing scores on the Coping Strategy Questionnaire predicted future depression after controlling for initial depression scores. These results suggest that Catastrophizing may make a significant con- tribution to the maintenance of depressive symptoms over and above any shared variance between the depression and catastrophizing measures. Similar methods could be used to determine if other cognitive coping strategies predict long-term psychological functioning, controlling for initial psychological functioning, and to examine whether behavioral coping strategies predict future physical functioning after controlling for initial physical functioning.

Some additional discussion concerning our catego- rization of pain coping strategies into wellness- and illness-focussed strategies is warranted. Several typolo- gies are possible, and indeed several are used in the pain coping literature. For example, in a previous study, we categorized coping strategies into 'cognitive' (thoughts people use to cope with pain) and 'behavioral' (activities people engage in to cope with pain), because we were interested in examining the relative importance of changes in beliefs and thoughts versus changes in behaviors in explaining treatment outcome (Jensen et al. 1994). However, the cognitive versus behavioral typology does not provide the clinician with an a priori reason to favor one coping strategy over another.

The motivating force behind the development of the CPCI was a desire to understand which pain coping strategies relate to treatment outcome from multidisci-

210

plinary treatment, and, eventually, to identify which individuals may benefit most from treatments designed to alter specific strategies. Current multidisciplinary treatment encourages strategies to maintain wellness (e.g., exercising, relaxing, persisting at tasks) and dis- courages strategies that are inconsistent with wellness maintenance, or which are most appropriately used when treating acute injury (e.g., immobilizing the in- jured area, resting and use medications). The catego- rization of strategies as wellness-focussed and illness- focussed thus allows for a identification of which coping strategies to target for intervention in multidisciplinary treatment, as well as for testing the model used in such treatment. However, 'illness-focussed' strategies may not necessarily be maladaptive for all individuals at all times. For example, an individual who expe- riences pain associated with a disease condition (such as cancer or arthritis) will likely benefit from coping strategies that are helpful for acute problems (e.g., analgesic medications). Indeed, there remains contro- versy concerning whether low-dose opioids may be helpful in the treatment of a selected group of chronic non-malignant pain patients (Schofferman 1993). In short, 'illness-focussed' strategies should be considered as just that; strategies usually recommended to individuals with a specific illness. Additional research is needed to determine for whom such strategies tend to be helpful, harmful, or neither.

To date, research has resulted in the development of at least two other measures of pain coping: the Vanderbilt Pain Management Inventory (Brown and Nicassio 1987) and the Coping Strategy Questionnaire (CSQ) (Rosenstiel and Keefe 1983). The CPCI is most similar in form to the CSQ. Both assess a variety of specific coping dimensions using multiple-item scales. In fact, the two appear to complement each other. Several of the pain coping dimensions that were repre- sented in the original item pool of the CPCI were

eliminated from the scale due to low reliability. These included distracting activities, reinterpreting pain, and ignoring pain. Because these strategies are already assessed well by the CSQ, we decided to forego the original goal of developing a comprehensive measure, and simply recommend that the CSQ be used if a measure of these cognitive coping dimensions is desired.

An important next step is to replicate the findings, across settings and in different samples of chronic pain patients, regarding the psychometric properties of the CPCI. It will also be important to see if the coping strategies assessed by this measure change as a result of multidisciplinary treatment, and if so, to identify those strategies most closely associated with treatment gains. Preliminary research, using single-item ratings of coping, suggests that changes in behavioral coping strategies may be less important than changes in beliefs and cognitive coping strategies in explaining the bene- fits of multidisciplinary treatment (Jensen et al. 1994). Replication of this research is needed to determine whether these findings hold up when a more reliable method of coping assessment (i.e., one that involves more than single-item measures) is used. Finally, studies are needed to examine the causal relationships between coping and adjustment to chronic pain, and such studies require reliable and valid measures of coping. The CPCI, in conjunction with other pain coping measures, such as the CSQ, may be useful in identifying the specific coping strategies that are most beneficial for specific patients.

Acknowledgement

This research was supported by a Graduate School Research Fund grant from the University of Washing- ton to the first author.

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APPENDIX I

CPCI: patient version

During the past week, how many days did you use each of the following at least once in the day to cope with your pain? (Note: You may have used some of these coping strategies on days that you did not have pain to prevent or minimize pain in the future. Please indicate the number of days you used each strategy F OR PAIN, whether or not you were experiencing pain at the time).

Number of days

1. Imagined a calming or distracting image to help me relax 2. Kept on doing what I was doing 3. Stretched the muscles in my legs and held the stretch for at least 10 seconds 4. Ignored the pain 5. I took a r e s t 6. Made ar rangements to see a friend or family member 7. I went to bed early to rest 8. I got support from a friend 9. Asked someone to do something for me

10. Reminded myself that things could be worse 11. Avoided using part of my body (e.g., hand, arm, leg) 12. Focussed on relaxing my muscles 13. Sat on the floor, stretched, and held the stretch at least l0 seconds 14. Told myself things will get better 15. Held on to something when getting up or sitting down 16. I got support from a family member 17. Exercised to s t rengthen the muscles in my arms for at least 1 minute 18. I rested as much as I could 19. Thought about someone with problems worse than mine 20. I talked to someone close to me 21. Told myself that I am adjusting to my pain problem better than many other people 22. Called a friend on the phone to help me feel better 23. Thought about all the good things I have 24. Listened to music to relax 25. Asked for help with a chore or task 26. Stretched the muscles in my neck (and held the stretch) for at least l0 seconds 27. Told myself my pain will get better 28. I didn' t let the pain interfere with my activities 29. Exercised to s t rengthen the muscles in my legs for at least 1 minute 30. Thought about a friend who has coped well with a problem 31. Listened to a relaxation tape to relax 32. Engaged in aerobic exercise (exercise that made my heart beat faster) for at least 15 minutes 33. Limited my walking because of pain 34. Just didn' t pay attention to the pain 35. Walked with a limp to decrease the pain 36. Meditated to relax 37. Reminded myself that I had coped with the pain before 38. Lay on my back, stretched, and held the stretch at least 10 seconds 39. Held part of my body (e.g., arm) in a special position 40. Rested in a chair or recliner 41. Avoided putting weight on feet or legs 42. Asked for help in carrying, lifting or pushing something 43. Exercised to improve my overall physical condition for at least 5 minutes 44. Talked to a friend or family member for support 45. Reminded myself that there are people who are worse off than I am 46. Limited my standing time 47. Lay down on a bed 48. Avoided some physical activities (lifting, pushing, carrying) 49. Reminded myself about things that I have going for me such as intelligence, good looks,

and good friends 50. Used self-hypnosis to relax 51. I just kept going 52. Exercised to s t rengthen the muscles in my stomach for at least l minute 53. Got together with a friend 54. Reminded myself that others have coped well with pain problems 55. Stretched the muscles where I hurt and held the stretch for at least 10 seconds 56. Avoided activity

0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7

0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7

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APPENDIX ! (continued).

Number of days

57. Got together with a family member 58. Went into a room by myself to rest 59. Used deep, slow breathing to relax 60. Exercised to s trengthen the muscles in my back for at least 1 minute 61. Stretched the muscles in my shoulders or arms, and held the stretch, for at least 10 seconds 62. Asked someone to get me something (e.g., medicine, food. drink) 63. Did not let the pain affect what I was doing 64. Lay down on a sofa 65. Please list each medication you took for pain during the past week, and indicate

the number of days you took each medication during the past week. Some common medications taken for pain are: Aspirin, Tylenol®, Advil®, Nuprin®, Naprosyn®, Percodan®, Tylenol #3®, Valium®, Soma®, Fiorinal®, and Flexeril®. However, there are many others, so please list ALL of the medications you are taking for pain. not just the ones listed above.

Please place a check mark here if you do not take any medications for pain []

0 2 3 4 5 6 7 0 2 3 4 5 6 7 0 2 3 4 5 6 7 0 2 3 4 5 6 7 0 2 3 4 5 6 7 0 2 3 4 5 6 7 0 2 3 4 5 6 7 0 2 3 4 5 6 7

N u m b e r o f d a y s

0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7 0 1 2 3 4 5 6 7

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A P P E N D I X II

CPCI: significant-other version

During the past week, how many days did your significant other (SO) use each of the following at least once in the day to cope with his or her pain? If you were unable to observe your SO enough to be able to accurately rate the number of days he or she used a coping strategy, please indicate this by circling ' U O ' ( 'unable to observe') for that strategy.

Number of days Unable to observe

1. Kept on doing what he or she was doing 0 1 2 3 4 5 6 7 UO 2. Stretched the muscles in his or her legs and held the stretch for at least 10 sec 0 1 2 3 4 5 6 7 U O 3. T o o k a r e s t 0 1 2 3 4 5 6 7 UO 4. Made ar rangements to see a friend or family member 0 1 2 3 4 5 6 7 UO 5. Went to bed early to rest 0 1 2 3 4 5 6 7 U O 6. Got support from a friend 0 1 2 3 4 5 6 7 UO 7. Asked someone to do something for him or her 0 1 2 3 4 5 6 7 U O 8. Avoided using part of his or her body (e.g., hand, arm, leg) 0 1 2 3 4 5 6 7 U O 9. Sat on the floor, stretched, and held the stretch at least 10 sec 0 1 2 3 4 5 6 7 U O

10. Held on to something when getting up or sitting down 0 1 2 3 4 5 6 7 U O 11. Got support from a family member 0 1 2 3 4 5 6 7 U O 12. Exercised to s t rengthen the muscles in his or her arms for at least 1 min 0 1 2 3 4 5 6 7 U O 13. Rested as much as he or she could 0 1 2 3 4 5 6 7 UO 14. Talked to someone close to him or her 0 1 2 3 4 5 6 7 U O 15. Called a friend on the phone to help him or her feel better 0 1 2 3 4 5 6 7 U O 16. Listened to music to relax 0 1 2 3 4 5 6 7 U O 17. Asked for help with a chore or task 0 1 2 3 4 5 6 7 UO 18. Stretched the muscles in his or her neck (and held the stretch) for at least 10 sec 0 1 2 3 4 5 6 7 UO 19. Didn ' t let the pain interfere with his or her activities 0 1 2 3 4 5 6 7 UO 20. Exercised to s t rengthen the muscles in his or her legs for at least 1 min 0 1 2 3 4 5 6 7 UO 21. Listened to a relaxation tape to relax 0 1 2 3 4 5 6 7 U O 22. Engaged in aerobic exercise (exercise that made his or her heart beat faster) 0 1 2 3 4 5 6 7 U O

for at least 15 minutes 23. Limited his or her walking because of pain 0 1 2 3 4 5 6 7 U O 24. Just didn' t pay attention to the pain 0 1 2 3 4 5 6 7 U O 25. Walked with a limp to decrease the pain 0 1 2 3 4 5 6 7 U O 26. Meditated to relax 0 1 2 3 4 5 6 7 U O 27. Lay on his or her back, stretched, and held the stretch at least 10 sec 0 1 2 3 4 5 6 7 UO 28. Held part of his or her body (e.g., arm) in a special position 0 1 2 3 4 5 6 7 U O 29. Rested in a chair or recliner 0 1 2 3 4 5 6 7 U O 30. Avoided putt ing weight on feet or legs 0 1 2 3 4 5 6 7 U O 31. Asked for help in carrying, lifting or pushing something 0 1 2 3 4 5 6 7 U O 32. Exercised to improve his or her overall physical condition for at least 5 min 0 1 2 3 4 5 6 7 U O 33. Talked to a friend or family member for support 0 1 2 3 4 5 6 7 U O 34. Limited his or her standing time 0 1 2 3 4 5 6 7 U O 35. Lay down o n a b e d 0 1 2 3 4 5 6 7 U O 36. Avoided some physical activities (lifting, pushing, carrying) 0 1 2 3 4 5 6 7 U O 37. Used self-hypnosis to relax 0 1 2 3 4 5 6 7 U O 38. Just kept going 0 1 2 3 4 5 6 7 U O 39. Exercised to s t rengthen the muscles in his or her s tomach for at least 1 min 0 1 2 3 4 5 6 7 U O 40. Got together with a friend 0 1 2 3 4 5 6 7 UO 41. Stretched the muscles where he or she hurt and held the stretch for at least 10 sec 0 1 2 3 4 5 6 7 UO 42. Avoided activity 0 1 2 3 4 5 6 7 UO 43. Got together with a family member 0 1 2 3 4 5 6 7 U O 44. Went into a room by him or herself to rest 0 1 2 3 4 5 6 7 U O 45. Used deep, slow breathing to relax 0 1 2 3 4 5 6 7 U O 46. Exercised to s t rengthen the muscles in his or her back for at least 1 min 0 1 2 3 4 5 6 7 U O 47. Stretched the muscles in his or her shoulders or arms, and held the stretch, 0 1 2 3 4 5 6 7 U O for at least 10 sec 48. Asked someone to get him or her something (e.g., medicine, food, drink) 0 1 2 3 4 5 6 7 U O 49. Did not let the pain affect what he or she was doing 0 1 2 3 4 5 6 7 U O 50. Lay down o n a s o f a 0 1 2 3 4 5 6 7 UO 51. Ignored the pain 0 1 2 3 45 6 7 UO

214

APPENDIX I1 (continued),

Number of days Unable to observe

52. Please list each medication your significant other took for pain during the past week, and indicate the number of days he or she took each medication during the past week. Some common medications taken for pain are: Aspirin, Tylenol®, Advil®, Nuprin(~). NaprosynC~, Percodan®, Tylenol #3®, Valium®, Soma®, Fiorinal®, and Flexeril®. However, there are many others, so please list ALL of the medications that you know your significant other is taking for pain, not just the ones listed above.

Please place a check mark here if your significan! other does not take any medications []

( 1 1 2 3 4 5 6 7 UO 0 1 2 3 4 5 6 7 UO 0 1 2 3 4 5 6 7 UO 0 1 2 3 4 5 6 7 UO 1 1 1 2 3 4 5 6 7 UO

215

APPENDIX III

Scoring the CPCI

General instructions for both patient and spouse versions: For scales, sum all the items responded to within the scale and divide by the number of items responded to. The scale score will always be between 0 and 7, with a 0 indicating that the respondent reported never using any of the coping strategies within a category during the last week, and a 7 indicating that the respondent reported using each coping strategy in a category every day. For medication use, first categorize the medications as containing opioids, sedative-hypnotics, and non-steroidal anti-inflammatory medications. Any medication containing an opioid or a sedative, count as an opioid and /o r sedative, respectively. Any medication containing a non-steroidal anti-inflammatory medication, and not containing an opioid or a sedative, categorize as a non-steroidal anti-inflammatory. Sum the number of days each medication category was taken. This number may be greater than 7 if a patient is taking more than one type of opioid and is taking each for more than 4 days each (i.e., Percocet® for 5 days and Darvocet® for 6 days out of the last 7 days equals a score of 11 for Opioid Medication Use).

Patient version scale items

Guarding: (11 + 15 + 33 + 35 + 39 + 41 + 46 + 48 + 56)/9 Resting: (5 + 7 + 18 + 40 + 47 + 58 + 64)/7 Asking for Assistance: (9 + 25 + 42 + 62)/4 Relaxation: (1 + 12 + 24 + 31 + 36 + 50 + 59)/7 Task Persistence: (2 + 4 + 28 + 34 + 51 + 63)/6 Exercise/Stretch: (3 + 13 + 17 + 26 + 29 + 32 + 38 + 43 + 52 + 55 + 60 + 61)/12 Seeking Social Support: (6 + 8 + 16 + 20 + 22 + 44 + 53 + 57)/8 Coping Self-Statements: (10 + 14 + 19 + 21 + 23 + 27 + 30 + 37 + 45 + 49 + 54)/11

Significant-other version scale items

Guarding: (8 + 10 + 23 + 25 + 28 + 30 + 34 + 36 + 42)/9 Resting: (3 + 5 + 13 + 29 + 35 + 44 + 50)/7 Asking for Assistance: (7 + 17 + 31 + 48)/4 Relaxation: (16 + 21 + 26 + 37 + 45)/5 Task Persistence: (1 + 19 + 24 + 38 + 49 + 51)/6 Exercise/Stretch: (2 + 9 + 12 + 18 + 20 + 22 + 27 + 32 + 39 + 41 + 46 + 47)/12 Seeking Social Support: (4 + 6 + 11 + 14 + 15 + 33 + 40 + 43)/8

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Documents

The chronic pain coping inventory: development and preliminary validation