Open access
Research Article
18 August 2023

Establishing cut-offs for the Pain Self-Efficacy Questionnaire for people living with chronic pain

Publication: Journal of Military, Veteran and Family Health
Volume 9, Number 4

LAY SUMMARY

LAY SUMMARY

Cut-offs were established for the Pain Self-Efficacy Questionnaire (PSEQ) by examining it with other clinical measures in 189 patients, including 69 Veterans, who attended a four-week interdisciplinary chronic pain management program. By dividing the PSEQ scores into low, medium, and high ranges, the authors examined the PSEQ’s association with fear of movement/re-injury (kinesiophobia), pain interference, and pain catastrophizing at admission and discharge from the program. Kinesiophobia was found to be most related to the proposed cut-offs. Findings support the use of PSEQ cut-offs when considering self-efficacy and kinesiophobia. Future research should evaluate these cut-offs with larger samples and functional/occupational measures. The findings show promise for individuals with chronic pain and continue to increase the understanding of the clinicians who work with these individuals.

Abstract

Introduction: This study aimed to establish clinically informed sub-group cut-offs for the Pain Self-Efficacy Questionnaire (PSEQ) by examining correlations and main and interaction effects of the PSEQ with other clinical measures and demographic data in a sample of individuals who attended a four-week interdisciplinary chronic pain management program. Methods: A sample of 189 patients (69 of whom were referred by Veterans Affairs Canada) who attended a four-week interdisciplinary chronic pain management program completed several pain-related measures at admission and discharge, including the PSEQ, Tampa Scale for Kinesiophobia (TSK-11), Pain Catastrophizing Scale (PCS), and Pain Disability Index (PDI). These measures were used to examine the discriminant validity of the PSEQ after dividing the PSEQ scores into three categories (low, medium, and high) based on the standard deviation. Results: The PSEQ at admission was significantly and negatively associated with the TSK, PDI, and PCS admission and discharge scores. The PSEQ cut-offs significantly interacted with the PSEQ and TSK scores at admission and discharge. However, the PSEQ cut-offs did not interact with the PCS or PDI. Discussion: Findings support the use of PSEQ cut-offs when considering the PSEQ and the TSK, with a specific focus on Veterans. Replication of this study with larger samples and functional/occupational measures is recommended. The study also highlights that Veterans may have specific needs and challenges when dealing with chronic pain and this population should be considered in developing and implementing pain management strategies regarding their self-efficacy.

Résumé

Introduction : Cette étude visait à établir des seuils de sous-groupes éclairés en clinique pour le questionnaire d’autoefficacité de la douleur (QAED) par l’examen des corrélations, des effets principaux et des effets d’interaction du QAED avec d’autres mesures cliniques et avec des données démographiques chez un échantillon de personnes qui ont participé à un programme interdisciplinaire de gestion de la douleur chronique pour une durée de quatre semaines. Méthodologie : Un échantillon de 189 patient(e)s (dont 69 ont été orienté[e]s par Anciens Combattants Canada) qui ont assisté à un programme interdisciplinaire de gestion de la douleur de quatre semaines se sont soumis(e)s à plusieurs mesures liées à la douleur à leur admission et à leur congé, y compris le QAED, l’échelle Tampa de kinésiophobie (TSK-11), l’échelle de catastrophisation de la douleur (ÉCD) et l’indice d’invalidité de la douleur (IID). Ces mesures ont été utilisés pour examiner la validité discriminatoire du QAED après avoir divisé les scores du QAED en trois catégories (faible, moyen et élevé) d’après l’écart-type. Résultats : Le QAED à l’admission était associé de manière significative et négative aux scores de la TSK, de l’IID et de l’ÉCD à l’admission et au congé. Les seuils du QAED interagissaient de manière significative avec les scores du QAED et de la TSK à l’admission et au congé. Cependant, ils n’interagissaient pas avec l’ÉCD ou l’IID. Discussion : Les observations appuient l’utilisation des seuils du QAED pour évaluer le QAED et la TSK, notamment auprès des vétéran(e)s. Il est recommandé de répliquer cette étude auprès d’échantillons plus vastes et de mesures fonctionnelles et professionnelles. L’étude démontre également que les vétéran(e)s peuvent avoir des besoins et des problèmes particuliers lorsqu’ils(elles) composent avec des douleurs chroniques. Il faudrait tenir compte de cette population pour créer et mettre en œuvre des stratégies de gestion de la douleur satisfaisantes sur le plan de l’autoefficacité.

INTRODUCTION

Chronic pain is yet to be fully understood by the scientific and clinical community. Understanding how to treat chronic pain and how to measure a patient’s progress through treatment is imperative. Literature on chronic pain provides strong evidence for the importance of psychosocial factors in the perception and experience of pain.1,2 Pain and disability are best understood and managed using the biopsychosocial model first introduced by Engel.3 In this model, the interplay of biological, psychological, and social factors is central in understanding health and disability.4
Because of the interplay of these three factors, literature on the diagnosis and measurement of pain is dominated by studies using various assessment tools to better assess the severity of a patient’s chronic pain. Grimmer-Somers et al.5 identified 45 assessment tools for patients with chronic pain as having good clinical utility and psychometric properties. These assessment tools were divided into five categories: pain severity, psychological distress, functional capacity, multidimensional constructs of persistent pain, and general health status/quality of life.5 This study will focus on psychological factors, since an individual’s perceptions of pain and disability can greatly affect their coping mechanisms.

Self-efficacy and chronic pain

Self-efficacy is a cognitive construct representing an individual’s belief or confidence in their skills and capabilities to accomplish a desired goal.6 Self-efficacy beliefs are important to assess in people living with chronic pain where frequent pain interference in daily activities and life results in diminished confidence in personal skills and capabilities.7 Bandura6 emphasizes that “efficacy expectations determine how much effort people will expend and how long they will persist in the face of obstacles and aversive experiences. The stronger the perceived self-efficacy, the more active the efforts.”6(p. 194)
In people with chronic pain, self-efficacy is used as a clinical tool not only to assess perceived skills and capabilities but also as an estimate of their ability to persist toward goals in the face of pain and to track progress over time. Self-efficacy is often linked to resiliency, or the ability to function despite distress.8 Both self-efficacy and resiliency affect an individual’s functional abilities, which is indicative of how psychological factors affect functioning in individuals with chronic pain.9 Resilience is also linked to better coping strategies, pain attitudes, and appropriate and effective medication use for individuals with chronic pain.8
Chronic pain is a common problem among Veterans, and they are at higher risk for developing chronic pain because of military service.10,11 This study includes a sample of Veterans and aims to contribute to the understanding of how to treat and measure progress in this population. By focusing on psychological factors such as self-efficacy, this study aims to provide insights into how these factors affect the experience of chronic pain in Veterans.

Pain Self-Efficacy Questionnaire (PSEQ)

The PSEQ is used for people with chronic pain to assess self-efficacy as a predictor of resiliency and less distress.7 The PSEQ focuses on measuring the ability of a person with chronic pain to manage and cope with pain in everyday life.7 A higher PSEQ score reflects stronger self-efficacy beliefs for patients to complete various functions, including household chores, socializing, and work, as well as coping without medication despite living with chronic pain. The PSEQ is found to be psychometrically sound for patients with chronic pain,7 with adequate internal consistency, test-retest reliability, and validity established using factor analysis and correlational studies.12

PSEQ and pain measures

Research has demonstrated the effectiveness of the PSEQ as a clinical predictive and outcome measure. Individuals with higher pain intensity and higher pain distress exhibited lower pain self-efficacy scores,13 and pain self-efficacy was shown to be predictive of a decrease in perceived disability and level of pain interference.14,15 Pain self-efficacy was also found to mediate the relationship between pain intensity and perceived disability both at the onset of chronic pain and at a 12-month follow-up.16 Moreover, Jochimsen et al.17 confirmed pain self-efficacy scores are inversely associated with pain intensity and pain distress in a sample of patients with femoroacetabular impingement syndrome. Thus, higher pain self-efficacy is associated with lower levels of perceived disability, pain interference, pain intensity, and pain distress.

PSEQ and psychological measures

Patients with chronic pain often experience negative thought processes, such as catastrophizing and kinesiophobia, in which a person has strong negative cognitive and emotional reactions to pain (catastrophizing) and fear of movement (kinesiophobia) because of their experience of chronic pain.18,19 The PSEQ is negatively associated with these two constructs, and also negatively associated with depressive symptoms, suggesting pain management programs should focus on improving the self-efficacy beliefs of patients to positively influence mental states and mental health.2022

PSEQ, occupational measures, and attrition

Higher self-efficacy was also found to be relevant to occupational functioning in people with chronic pain, where greater self-efficacy was predictive of return to work after participation in a pain management program23 and was associated with greater occupational performance as measured using the Canadian Occupational Performance Measure (COPM).24,25 Self-efficacy was also a significant component of attending follow-up health care appointments.21 Those who did not attend a six-month follow-up had an average self-efficacy score of 36.9 at the end of their pain management programs and 32.9 at a 12-month follow-up, compared with attenders’ average scores of 41.8 and 40.6, respectively. These differences also show the PSEQ score of attenders was more stable than that of non-attenders.

Establishing cut-offs for the PSEQ

Research has yet to establish clinical cut-off scores for the PSEQ, which can help to denote severity categorizations and the needs of patients5 and identify salient areas for intervention. At the Michael G. DeGroote Pain Clinic, the clinic from which this study derived data, cut-off scores are used for the Pain Catastrophizing Scale (PCS),18 the Center for Epidemiological Studies Depression Scale (CES-D),26 and the Clinical Anxiety Scale (CAS).27 Such cut-offs guide diagnosis and treatment and reassure clinicians about decision making and assessments.
In terms of the PSEQ, cut-offs would give clinicians a quick overview of patient scores. For example, a clinician would understand that patients with low self-efficacy may need more psychological support (cognitive behavioural therapy and/or motivational interviewing) to help establish motivation to complete goals and change unhelpful thinking styles. Patients with medium self-efficacy may need to continue with psychological support while also building on rehabilitation components of treatment. Patients with high self-confidence may simply need help maintaining behavioural changes, with a more significant focus on the progression of activity and goals.
This study aims to establish cut-off severity scores for the PSEQ by comparing its scores to those of well-established measures used in chronic pain research and assessments. Several factors may make establishing pain self-efficacy questionnaire cut-off scores particularly relevant and beneficial for Veterans. One such factor is the high prevalence of chronic pain among Veterans, which is often linked to military service and may be further compounded by other physical and psychological health conditions.11,28 Veterans may also be at increased risk for developing chronic pain through exposure to traumatic events during military service, as well as the unique stressors and challenges they may face upon returning to civilian life.11
Overall, while the benefit of establishing pain self-efficacy questionnaire cut-off scores may be similar for both Veterans and non-Veterans, the specific context and challenges faced by Veterans may make these cut-off scores particularly relevant and beneficial for this population.

METHODS

Participants

Participants included 189 patients (69 of whom were referred by Veterans Affairs Canada) with chronic pain participating in the four-week Intensive Chronic Pain Management Program at the Michael G. DeGroote Pain Clinic between July 2015 and January 2020. The mean age of participants was 48 years (SD = 11.72), 54% were male, 50% were married, and most participants had elementary (35.1%) and high school (35.8%) education levels. Participants had heterogeneous chronic pain conditions, which they experienced for an average of 11.9 years (SD = 10.19). Most participants (73.5%) were not working at the time of initial assessment, had been referred related to a motor vehicle accident (MVA) (47.6%) or from Veterans Affairs Canada (36.5%), and reported their pain problems resulted from an MVA (40.7%), work-/service-related injury (38.6%), or both (5.8%). Table 1 shows the demographic characteristics of the study sample. Regarding past health care use, participants reported an average of 17 visits (SD = 6.19) to family physicians and 6 to specialists (SD = 5.4), and had made 3.4 visits (SD = 4.9, range = 0–22) to the emergency department since the onset of pain.
Table 1. Patient demographic information
DemographicsStatistical information
Age in years Mean: 48 years
 SD: 11.72 years
 Range: 21–71
Gender Females: 87 (46%)
 Males: 102 (54%)
Referral source Veterans Affairs Canada: 69 (36.5%)
 Insurance: 90 (47.6%)
 WSIB: 18 (9.5%)
 OHIP: 9 (4.8%)
 Self-pay: 1 (0.5%)
 Unknown: 1 (0.5%)
 1 missing entry
Current marital status Single: 31 (16.4%)
 Married: 95 (50.3%)
 Separated: 10 (5.3%)
 Divorced: 16 (8.5%)
 Common-law: 31 (16.4%)
 Widowed: 4 (2.1%)
 2 missing entries
Number of children None: 44 (23.3%)
 1–2: 88 (46.6%)
 3+: 55 (29.1%)
 2 missing entries
Current employment status No: 139 (73.5%)
 Yes: 47 (24.9%)
 3 missing entries
Education Elementary school: 163 (35.1%)
 High school: 166 (35.8%)
 University: 48 (10.3%)
 Another post-secondary path: 87 (18.8%)
Total number of injuries related to work Mean: 3
 SD: 5.45
 Range: 0–22
 25 missing entries
Total number of injuries for reasons other than work (e.g., car accident) Mean: 1.9
 SD: 1.92
 Range: 0–6
 64 missing entries
How did your pain first begin? Did it begin after … Work-related injury: 73 (38.6%)
 Motor-vehicle accident: 77 (40.7%)
 Neither: 15 (7.9%)
 Both: 11 (5.8%)
 13 missing entries
Number of years since pain problem began Mean: 11.86
 SD: 10.19
 Range: 1.96–52.24
 18 missing entries
How many times have you seen your physician since your pain problem began? Mean: 17.14
 SD: 6.19
 Range: 1–22
 24 missing entries
How many specialists have you seen since your pain problem began? Mean: 6.6
 SD: 5.4
 Range: 0–22
 16 missing entries
How many times have you gone to the emergency room since your pain problem began? Mean: 3.4
 SD: 4.9
 Range: 0–22
 17 missing entries
WSIB = Workplace Safety and Insurance Board; OHIP = Ontario Health Insurance Plan.

Program

The Michael G. DeGroote Pain Clinic’s four-week program is an intensive, group-based, interdisciplinary pain management program based on the biopsychosocial model of assessment, prevention, and treatment of chronic pain. The program’s goals emphasize patients learning and applying pain-related coping strategies at home and work. The program incorporates fitness, occupational therapy, group therapy, medication management, psychoeducation, social work, and a variety of other services. These services are provided by a care group of physicians, psychologists, social workers, physiotherapists, psychometrists, occupational therapists, pharmacists, dieticians, and support staff.
Patients are referred to the program by various health care providers, including physicians, Veteran Affairs Canada, MVA Insurance, and the Workplace Safety and Insurance Board (WSIB). The program comprises a patient sample of both Veterans and civilians and is third party funded. All participants provided informed written consent to participate.

Measures

At admission and discharge to the program (described by Hapidou et al.),29 participants completed several measures, including the PSEQ,7 PCS,18 Pain Disability Index (PDI),3032 and Tampa Scale for Kinesiophobia (TSK-11).19
The PSEQ is a 10-item self-report scale that requires participants to rate their confidence in their ability to perform functionally and live their everyday lives. Items are rated on a 7-point scale ranging from 0 (not at all confident) to 6 (completely confident).7 The PSEQ has high test-retest reliability and high internal reliability12 and was found to be highly correlated with measures of pain-related disability, coping mechanisms, and the Self-Efficacy Scale, which is an activity-specific measure of self-efficacy.33
The PCS is a 13-item scale that measures exaggerated cognitive and emotional responses to pain, including rumination, magnification, and helplessness.18 Each item is rated on a 5-point scale ranging from 0 (not at all) to 4 (all the time). The PCS has established validity and reliability. This program used a 14-item PCS scale, with an extra item to assess for belief that life is not worth living because of pain.
The PDI is a 7-item self-report scale used to assess the extent of interference of pain in various life activities.3032 Individuals use an 11-point scale ranging from 0 (no disability) to 10 (total disability) to rate their perceived interference of pain in seven categories of life activities: family/home responsibilities, recreation, social activity, occupation, sexual behaviour, self-care, and life support activity. The PDI has established validity and reliability.30
The TSK-11 is an 11-item self-report measure of fear of movement/reinjury because of pain. Each item is rated using a 4-point scale from 1 (strongly disagree) to 4 (strongly agree). The psychometric properties of TSK-11 have been described by Woby et al.19 The TSK-11 is scored identically to the original version, except that there are no reverse-coded items, and higher scores signify greater fear of re-injury due to movement.19,34

Procedure

Ethics approval for this study was obtained in July 2021. Patients completed the measures detailed above at admission and discharge from the four-week Intensive Chronic Pain Management Program at the Michael G. DeGroote Pain Clinic. The patients also provided informed consent for their data to be used in this study.

Analysis

Data were analyzed using SPSS (IBM Statistical Package for the Social Sciences). Participants were divided into three PSEQ sub-groups according to the sub-group values of PSEQ at admission. Pearson correlation coefficients were used to calculate correlations between all quantitative measures. Analyses of variance (ANOVA) with a repeated measures design were used to examine changes recorded at admission and discharge for the PSEQ, PCS, PDI, and TSK. Gender, referral source, and the PSEQ sub-groups were set as the between-group factors. Unfortunately, a large multivariate ANOVA was not feasible as some factors did not have enough patients for meaningful analysis. Effect sizes were calculated using Cohen’s d.

RESULTS

Descriptive statistics

Patients’ scores on all four measures were analyzed at admission and discharge. Descriptive statistics can be seen in Tables 2 and 3, as well as Figures 1 to 4. Self-efficacy (PSEQ) generally increased, while pain catastrophizing (PCS), pain disability (PDI), and kinesiophobia (TSK) scores generally decreased from admission to discharge.
PSEQ = Pain Self-Efficacy Questionnaire.
Figure 1. Histogram of PSEQ admission and discharge scores (scores range from 0–60)
PCS = Pain Catastrophizing Scale.
Figure 2. Histogram of PCS admission and discharge scores (scores range from 0–56)
PDI: Pain Disability Index.
Figure 3. Histogram of PDI admission and discharge scores (scores range from 0–70)
TSK = Tampa Scale of Kinesiophobia.
Figure 4. Histogram of TSK admission and discharge scores (scores range from 11–44)
Table 2. Descriptive statistics of PSEQ, PCS, PDI, and TSK at admission (N = 189)
 PSEQ AdmissionPCS AdmissionPDI AdmissionTSK Admission
Range0–520–5519–7013–44
Mean21.6130.8947.2330.79
SD10.3912.609.896.60
Median22324831
Mode21 & 9385035
PSEQ = Pain Self-Efficacy Questionnaire; PCS = Pain Catastrophizing Scale; PDI = Pain Disability Index; TSK = Tampa Scale of Kinesiophobia.
Table 3. Descriptive statistics of PSEQ, PCS, PDI, and TSK at discharge (N = 189)
 PSEQ DischargePCS DischargePDI DischargeTSK Discharge
Range0–590–528–6711–42
Mean33.4120.2540.5824.54
SD10.7112.2111.907.00
Median34194224
Mode40 & 3820 & 1047 & 4623
PSEQ: Pain Self-Efficacy Questionnaire; PCS: Pain Catastrophizing Scale; PDI: Pain Disability Index; TSK: Tampa Scale of Kinesiophobia

Correlational analysis

Correlations between admission and discharge scores of all four measures were calculated. The PSEQ admission scores were significantly negatively associated with the admission and discharge scores of the PCS, PDI, and TSK, and positively associated with the discharge scores of the PSEQ. All correlations between measures at admission and discharge can be found in Table 4.
Table 4. Correlational analysis of PSEQ, PCS, PDI, and TSK at both admission and discharge
 PSEQ AdmissionPCS AdmissionPDI AdmissionTSK AdmissionPSEQ DischargePCS DischargePDI DischargeTSK Discharge
PSEQ Admission1.00-0.45-0.41-0.250.60-0.47-0.37-0.39
PCS Admission 1.000.340.54-0.310.610.24*0.48
PDI Admission  1.000.28-0.420.270.570.25
TSK Admission   1.00-0.240.310.23*0.45
PSEQ Discharge    1.00-0.52-0.51-0.48
PCS Discharge     1.000.400.69
PDI Discharge      1.000.35
TSK Discharge       1.00
*
p ≤ 0.01;
p ≤ 0.001.
PSEQ = Pain Self-Efficacy Questionnaire; PCS = Pain Catastrophizing Scale; PDI = Pain Disability Index; TSK = Tampa Scale of Kinesiophobia.

Data analysis of the sub-group breakdown of the PSEQ

The PSEQ was subdivided into three categories based on the mean (21.61) and standard deviation (10.39) of the PSEQ admission scores, following similar procedures used in other studies18,35 in which upper and lower thirds of the distribution of scores established the cut-off scores. Low PSEQ scores ranged from 0 to 11, as 11 (–~ 11.22) is equal to the mean subtracted by one standard deviation. Medium PSEQ scores ranged from 12 to 32, as 32 is equal to the mean plus one standard deviation. High PSEQ scores ranged from 33 to 60. After the establishment of sub-groups, individuals were placed in the low, medium, or high PSEQ sub-group based on PSEQ scores at admission. Table 5 shows the breakdown of sub-groups and the number of patients per sub-group. Using these sub-groups, factorial ANOVAs with repeated measures was performed on data using three between-subjects factors: levels of PSEQ, gender, and referral source.
Table 5. Breakdown of PSEQ subgroup scores at admission
Sub-groupsScore rangesPatients (N)MeanSD
Low PSEQ0–11407.382.89
Medium PSEQ12–3212322.675.48
High PSEQ33–602638.505.04
PSEQ = Pain Self-Efficacy Questionnaire.

Change in PSEQ scores

When conducting ANOVAs on patients’ PSEQ scores according to interaction with the established sub-groups of PSEQ admission scores, an interaction and a main effect were found. Results revealed a significant within-subjects effect for PSEQ scores between admission and discharge (F1,186 = 220.55, p < 0.001) with a large effect size (1.12), indicating that PSEQ scores increased significantly at discharge. This is evident in Tables 2 and 3, as the difference in means of PSEQ admission and discharge was 12, much larger than the reported minimal clinically important difference (MCID) of 9 found by Maughan and Lewis36 or the MCID range of 5.5 to 8.5 and minimal detectable change (MDC) of 11.52 reported by Dubé et al.37 The mean differences of PSEQ scores between admission and discharge of patients with low (admission scores ranging from 0 to 11), medium (admission scores ranging from 12 to 32), and high (admission scores ranging from 33 to 60) PSEQ scores were 18.01 (p < 0.001), 11.11 (p < 0.001), and 5.44 (p = 0.006), respectively. No other main effects or interactions were found (p > 0.05).

Relationships between PSEQ sub-groups and PCS

Results of the analysis on the PCS revealed a significant within-subjects effect for PCS scores between admission and discharge (F1,186 = 103.87, p < 0.001) with a large effect size (0.86). This shows that PCS scores decreased significantly at discharge. There was a significant between-subjects effect for referral source (Veteran vs. civilian, F1,183 = 3.93, p = 0.049) and a significant interaction effect between PCS at both treatment stages and referral source (F1,183 = 14.35, p < 0.001), as can be seen in Figure 6. The mean difference on the PCS between Veterans and civilians was not significant at admission but was significant at discharge, with a difference of 7.74 (p < 0.001). No other main effects or interactions were found (p > 0.05), notably with no significant interaction effect found between the PSEQ sub-group division and PCS scores at admission and discharge (p > 0.05).
PSEQ = Pain Self-Efficacy Questionnaire.
Figure 5. Interaction effect: Mean (SEM) PSEQ scores at admission and discharge by PSEQ sub-groups established at admission
PCS = Pain Catastrophizing Scale.
Figure 6. Interaction effect: Mean (SEM) PCS scores at admission and discharge by referral source

Relationships between PSEQ sub-groups and PDI

Results of the analysis on the PDI revealed a significant within-subjects effect for PDI scores between admission and discharge (F1,186 = 63.60, p < 0.001) with a medium effect size (0.61). This indicates that PDI scores decreased significantly at discharge. No other main effects or interactions were found (p > 0.05), notably with no significant interaction effect found between the PSEQ sub-group division and PDI scores at admission and discharge (p > 0.05).

Relationships between PSEQ sub-groups and TSK

Results of the analysis on the TSK revealed a significant within-subjects effect for TSK scores between admission and discharge (F1,186 = 78.58, p < 0.001) with a large effect size (0.92) indicating that TSK scores decreased significantly at discharge. There was also a significant interaction effect between the PSEQ sub-group division and TSK scores at admission and discharge (F2,183 = 5.23, p = 0.006), as can be seen in Figure 7. The mean differences of TSK scores between admission and discharge for patients in the low, medium, and high PSEQ sub-groups, based on their PSEQ admission scores, were −3.41 (p = 0.002), −7.25 (p < 0.001), and −4.40 (p = 0.005), respectively. There was a significant interaction effect between TSK at treatment stages and referral source (F1,183 = 18.99, p < 0.001), as the mean difference in TSK scores between Veteran and civilians was not significant at admission but it was at discharge, with a mean difference of −3.43 (p = 0.008). There was also a significant interaction between TSK at treatment stages and gender (F1,183 = 4.54, p = 0.034), as the mean difference in TSK scores between males and females was 3.34 (p = 0.006) at admission but it was not significant at discharge. These interactions can be seen in Figures 8 and 9, respectively. No other main effects or interactions were found (p > 0.05).
PSEQ = Pain Self-Efficacy Questionnaire; TSK = Tampa Scale of Kinesiophobia.
Figure 7. Interaction effect: Mean (SEM) TSK scores at admission and discharge by PSEQ sub-groups established at admission
TSK = Tampa Scale of Kinesiophobia.
Figure 8. Interaction effect: Mean (SEM) TSK scores at admission and discharge by referral source
TSK = Tampa Scale of Kinesiophobia.
Figure 9. Interaction effect: Mean (SEM) TSK scores at admission and discharge by gender sub-groups

DISCUSSION

The purpose of this study was to establish clinically informed sub-group cut-offs for the PSEQ by examining correlations, interactions, and main effects of the PSEQ with other clinical measures and demographic data. Past studies established the PSEQ is associated with other clinical measures, but none have established cut-offs that clinicians could use when assessing and treating a patient with chronic pain. Results of this study can help inform clinicians of the use of the PSEQ as a predictive and benchmarking measure.
PSEQ admission scores were moderately positively correlated with PSEQ discharge scores, meaning those starting with a greater PSEQ score at admission tended to have a greater PSEQ score at discharge and vice versa. This positive correlation was anticipated, as the rehabilitation program aims to increase patients’ self-efficacy through cognitive-behaviourally informed treatment. Furthermore, PSEQ admission and discharge scores were weakly to moderately negatively associated with the PCS, PDI, and TSK admission and discharge scores. These results align with those of previous studies.12,2022 Again, these associations were expected, as self-efficacy fundamentally opposes catastrophizing, kinesiophobia, and belief that one is disabled. Understandably, catastrophizing, kinesiophobia, and belief that one is disabled co-occur in patients with chronic pain, as discussed by Sullivan et al.18 and Woby et al.19 There was also a significant between-subjects effect of the PSEQ sub-group levels, indicating patients of each sub-group were truly different from one another. Also, all four measures changed both statistically and clinically significantly from admission to discharge at the interdisciplinary rehabilitation program.

Interactions and main effects

Importantly, the PSEQ sub-groups interacted with the two clinical measures: PSEQ and TSK. The interaction between the sub-groups and the PSEQ revealed change in an individual’s self-efficacy score from admission to discharge was dependent on their level of self-efficacy at admission. As previously mentioned, the mean differences of PSEQ scores between admission and discharge of patients with low PSEQ were 18.01 (p < 0.001), medium PSEQ was 11.11 (p < 0.001), and high PSEQ was 5.44 (p = 0.006), with the sub-groups determined by the patients’ PSEQ scores at admission. These results indicated those in the low PSEQ group made the greatest increase from admission to discharge, those in the medium PSEQ group made a moderate increase from admission to discharge, and those in the high PSEQ group made the smallest increase from admission to discharge. Results also showed patients with low PSEQ had a mean difference twice that required for MCID, those with medium PSEQ had a mean difference well above the MCID threshold, and those with high PSEQ scores had a mean difference below the MCID threshold.36 This understanding of the different possibilities of improvement between PSEQ levels can be very informative to clinicians treating individuals with chronic pain. This differential change could show the program is effective in helping those most adversely affected or simply that those with higher self-efficacy have less possible room for improvement.
The interaction between the sub-groups and the TSK revealed the reduction of an individual’s kinesiophobia score from admission to discharge depended on their self-efficacy at admission. Results showed those in the low and medium PSEQ sub-groups had similar TSK scores at admission, while those in the high PSEQ group significantly differed from both low and medium groups. Interestingly, at discharge, the medium and high PSEQ groups had similar TSK scores, while those in the low PSEQ group made significantly less improvement than the medium group.
The PSEQ sub-groups did not interact with the PCS or the PDI scores. This may simply mean that catastrophizing and belief that one is disabled are not wholly dependent on self-efficacy, but that does not mean they are not related. The relationship between PSEQ sub-groups and the PCS or PDI can be an avenue for future research, and a test of interactions with the sub-groups shown here should be replicated.
In addition to the clinical measures’ interactions with the three PSEQ levels, both the PCS and the TSK significantly interacted with the referral source. The interaction between referral source and PCS scores revealed that both Veterans and civilians had similar PCS admission scores; however, Veterans had lower PCS scores than civilians at discharge. Additionally, the interaction between referral source and TSK scores revealed that Veterans had larger TSK admission scores than civilians; however, Veterans had lower TSK discharge scores than civilians. In these two interactions, Veterans experienced significantly greater improvements than civilians following treatment. These results supported those of Jomy and Hapidou38 in that Veterans experienced significantly greater differences between admission and discharge in pain catastrophizing, kinesiophobia, and a number of other measures compared with civilians.
The final interaction involves gender and TSK scores at admission and discharge. Males had significantly larger TSK admission scores than females; however, at discharge, both males and females had similar scores, meaning that while both males and females had significant improvements, males had greater improvements on the TSK compared to females. The role of gender on psychological factors continues to be a source of debate in the field, as beliefs tend to elicit different coping behaviours in males and females. These results support those of Bränström and Fahlström,39 who found men had higher levels of kinesiophobia than women. Studies also found men tend to report greater fear than women, despite women reporting greater pain and anxiety. These findings suggest that fear influences the types of coping behaviours in which one engages, which differ by gender.40

Limitations and future studies

A limitation of this study was the use of a convenience sample of patients with complete data sets to help establish a preliminary estimate of clinical cut-offs for the PSEQ in the literature. Future research should refine these estimates using a broad sampling of diverse patient populations across various settings to also understand any between and within group differences in pain self-efficacy and any interaction between these factors and patient outcomes (e.g., program completers vs. non-completers).
In addition, a caveat to these findings is that participants were from heterogeneous groups based on the context that resulted in the onset of their chronic pain problem, and with associated third-party involvement (e.g., MVA vs. Canadian Armed Forces Veteran). Veterans also demonstrated a greater level of improvement relative to civilians, raising questions about between-group differences in these populations. While there are shared factors, such as perceived injustice,41 underlying the chronic pain-related outcomes in Veterans and civilians, future research should investigate between-group differences in pain self-efficacy and other pain-related factors associated with outcome. As this was simply an analysis of demographics, the authors recommend further research on the differentiation between Veterans’ and civilians’ psychological improvement.
Another important change that should be implemented in future studies is the analysis of PSEQ cut-offs in relation to occupational measures. Due to the large number of patients with chronic pain not returning to work, it would be important to understand whether a specific sub-group PSEQ level is linked to return to work.23 If so, clinicians can identify patients that need more, or less, focus on specific treatments to increase self-efficacy and encourage returning to work. Thus, it is important to validate the results found with PSEQ cut-offs within this study by replicating this study with larger sample sets, data sets, and clinical measures with the ability to run multivariate ANOVA models.

REGISTRY AND REGISTRATION NO. OF THE STUDY/TRIAL

N/A

ANIMAL STUDIES

N/A

PEER REVIEW

This article has been peer reviewed.

REFERENCES

1.
Penlington C, Urbanek M, Barker S. Psychological theories of pain. Prim Dent J. 2018;7:24–9.
2.
Turk DC, Okifuji A. Psychological factors in chronic pain: evolution and revolution. J Consult Clin Psychol. 2002;70:678–90. Medline:12090376
3.
Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129–36. Medline:847460
4.
Vlaeyen JWS, Crombez G, Goubert L. The psychology of chronic pain and its management. Phys Ther Rev. 2007;12:179–88.
5.
Grimmer-Somers K, Kumar S, Vipond N, et al. Primary care assessment instruments for patients at risk of, or with, persistent pain: opportunistic findings from a systematic literature review. Int J Gen Med. 2009;2:121–8. Medline:20360895
6.
Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Adv Behav Res Ther. 1978;1:139–61.
7.
Nicholas MK. The Pain Self-Efficacy Questionnaire: taking pain into account. Eur J Pain. 2007;11:153–63. Medline:16446108
8.
Karoly P, Ruehlman LS. Psychological “resilience” and its correlates in chronic pain: findings from a national community sample. Pain. 2006;123:90–7. Medline:16563626
9.
Ahmed SA, Shantharam G, Eltorai AEM, et al. The effect of psychosocial measures of resilience and self-efficacy in patients with neck and lower back pain. Spine J. 2019;19:232–7. Medline:29906617
10.
Gallagher RM. Advancing the pain agenda in the veteran population. Anesthesiol Clin. 2016;34: 357–78. Medline:27208715
11.
Gauntlett-Gilbert J, Wilson S. Veterans and chronic pain. Br J Pain. 2013;7:79–84. Medline:26516504
12.
Asghari A, Nicholas MK. Pain self-efficacy beliefs and pain behaviour. A prospective study. Pain. 2001;94:85–100. Medline:11576748
13.
Williams AC, Nicholas MK, Richardson PH, et al. Evaluation of a cognitive behavioural programme for rehabilitating patients with chronic pain. Br J Gen Pract. 1993;43:513–18.
14.
Ayre M, Tyson GA. The role of self-efficacy and fear-avoidance beliefs in the prediction of disability. Aust Psychol. 2001;36:250–3.
15.
Strong J, Westbury K, Smith G, et al. Treatment outcome in individuals with chronic pain: is the Pain Stages of Change Questionnaire (PSOCQ) a useful tool? Pain. 2002;97:65–73. Medline:12031780
16.
Costa L da CM, Maher CG, McAuley JH, et al. Self-efficacy is more important than fear of movement in mediating the relationship between pain and disability in chronic low back pain. Eur J Pain Lond Engl. 2011;15:213–19. Medline:20655254
17.
Jochimsen KN, Mattacola CG, Noehren B, et al. Low self-efficacy and high kinesiophobia are associated with worse function in patients with femoroacetabular impingement syndrome. J Sport Rehabil 2020;30:445–51. Medline:33027764
18.
Sullivan MJL, Bishop SR, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess. 1995;7:524–32.
19.
Woby SR, Roach NK, Urmston M, et al. Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain. 2005;117: 137–44. Medline:16055269
20.
Barry LC, Guo Z, Kerns RD, et al. Functional self-efficacy and pain-related disability among older veterans with chronic pain in a primary care setting. Pain. 2003;104:131–7. Medline:12855322
21.
Coughlan GM, Ridout KL, Williams AC, et al. Attrition from a pain management programme. Br J Clin Psychol. 1995;34:471–9. Medline:8845785
22.
Williams AC de C, Richardson PH, Nicholas MK, et al. Inpatient vs. outpatient pain management: results of a randomised controlled trial. Pain. 1996;66:13–22. Medline:8857627
23.
Adams JH, Williams AC de C. What affects return to work for graduates of a pain management program with chronic upper limb pain? J Occup Rehabil. 2003;13:91–106.
24.
Thomas F, Gibson SJ, Arnold CA, et al. Effects of a pain management programme on occupational performance are influenced by gains in self-efficacy. Br J Occup Ther. 2021;84:410–20.
25.
van Huet H, Williams D. Self-beliefs about pain and occupational performance: A comparison of two measures used in a pain management program. OTJR Occup Particip Health. 2007;27:4–12.
26.
Geisser ME, Roth RS, Robinson ME. Assessing depression among persons with chronic pain using the Center for Epidemiological Studies-Depression Scale and the Beck Depression Inventory: a comparative analysis. Clin J Pain. 1997;13:163–70. Medline:9186024
27.
Westhuis D, Thyer BA. Development and validation of the clinical anxiety scale: a rapid assessment instrument for empirical practice. Educ Psychol Meas. 1989;49:153–63.
28.
Shipherd JC, Keyes M, Jovanovic T, et al. Veterans seeking treatment for posttraumatic stress disorder: What about comorbid chronic pain? J Rehabil Res Dev. 2007;44:153. Medline:17551870
29.
Hapidou EG, Hanna C, Borg Debono VB, et al. Qualitative analysis of long-term chronic pain program management outcomes: Veterans and civilians. J Mil Veteran Fam Health. 2022;8(2):51–61.
30.
Pollard CA. Preliminary validity study of the Pain Disability Index. Percept Mot Skills. 1984;59:974. Medline:6240632
31.
Tait RC, Pollard CA, Margolis RB, et al. The pain disability index: psychometric and validity data. Arch Phys Med Rehabil. 1987;68:438–41.
32.
Grönblad M, Hupli M, Wennerstrand P, et al. Intercorrelation and test-retest reliability of the Pain Disability Index (PDI) and the Oswestry Disability Questionnaire (ODQ) and their correlation with pain intensity in low back pain patients. Clin J Pain. 1993;9:189–95. Medline:8219519
33.
Kaivanto KK, Estlander AM, Moneta GB, et al. Isokinetic performance in low back pain patients: the predictive power of the self-efficacy scale. J Occup Rehabil. 1995;5:87–99. Medline:24234579
34.
Hapidou EG, O’Brien MA, Pierrynowski MR, et al. Fear and avoidance of movement in people with chronic pain: psychometric properties of the 11-item Tampa Scale for Kinesiophobia (TSK-11). Physiother Can. 2012;64:235–41. Medline:23729957
35.
Lüning Bergsten C, Lundberg M, Lindberg P, et al. Change in kinesiophobia and its relation to activity limitation after multidisciplinary rehabilitation in patients with chronic back pain. Disabil Rehabil. 2012;34:852–8. Medline:22214399
36.
Maughan EF, Lewis JS. Outcome measures in chronic low back pain. Eur Spine J. 2010;19:1484–94. Medline:20397032
37.
Dubé MO, Langevin P, Roy JS. Measurement properties of the Pain Self-Efficacy Questionnaire in populations with musculoskeletal disorders: a systematic review. Pain Rep. 2021;6:e972. Medline:34963996
38.
Jomy J, Hapidou EG. Pain management program outcomes in veterans with chronic pain and comparison with nonveterans. Can J Pain. 2020;4:149–61. Medline:33987494
39.
Bränström H, Fahlström M. Kinesiophobia in patients with chronic musculoskeletal pain: Differences between men and women. J Rehabil Med. 2008;40:375–80. Medline:18461263
40.
Stubbs D, Krebs E, Bair M, et al. Sex differences in pain and pain-related disability among primary care patients with chronic musculoskeletal pain. Pain Med. 2010;11:232–9. Medline:20002591
41.
Carriere JS, Donayre Pimentel S, Yakobov E, et al. A systematic review of the association between perceived injustice and pain-related outcomes in individuals with musculoskeletal pain. Pain Med Malden Mass. 2020;21:1449–63. Medline:32377686

Information & Authors

Information

Published In

Go to Journal of Military, Veteran and Family Health
Journal of Military, Veteran and Family Health
Volume 9Number 4September 2023
Pages: 50 - 62

History

Received: 26 January 2023
Revision received: 14 March 2023
Accepted: 23 March 2023
Published ahead of print: 18 August 2023
Published in print: September 2023
Published online: 6 October 2023

Key Words:

  1. Canada
  2. chronic pain
  3. cut-offs
  4. Pain Self-Efficacy Questionnaire
  5. PSEQ
  6. self-efficacy
  7. Veterans

Mots-clés : 

  1. autoefficacité
  2. Canada
  3. douleur chronique
  4. QAED
  5. questionnaire d’autoefficacité de la douleur
  6. seuils
  7. vétéran(e)s

Authors

Affiliations

Bishay Freddy
Biography: Freddy Bishay is currently in his final semester of a bachelor of science degree in psychology, neuroscience, and behaviour, specializing in mental health at McMaster University. He has conducted research on topics such as pain self-efficacy, moral injury, and posttraumatic stress disorder among health care workers during the COVID-19 pandemic. He has also authored articles and sections in textbooks, and his research interests include mental health, resiliency, and health care education.
Department of Psychology, Neuroscience & Behaviour, McMaster University, Hamilton, Ontario, Canada
Tippin Gregory K.
Biography: Gregory K. Tippin, PhD, CPsych, is a psychologist at Hamilton Health Sciences working in chronic pain management. He is an Assistant Professor (part-time) in the Department of Psychiatry and Behavioural Neurosciences.
Michael G. DeGroote Pain Clinic, Hamilton Health Sciences, Hamilton, Ontario, Canada
Fransson Adria
Biography: Adria Fransson, BHSc, PT, is a physiotherapist at Hamilton Health Sciences who has been working for over 20 years, primarily in chronic pain management and pelvic pain.
Michael G. DeGroote Pain Clinic, Hamilton Health Sciences, Hamilton, Ontario, Canada
Hapidou Eleni G.
Biography: Eleni G. Hapidou, PhD, CPsych, has been a psychologist at Hamilton Health Sciences for over 30 years, working primarily in chronic pain management. She is an Associate Professor (part-time) in the Department of Psychiatry and Behavioural Neurosciences with a cross-appointment in Psychology, Neuroscience and Behaviour at McMaster University. She has published in diverse pain areas. She is an Executive Member of the Institute of Pain Research and Care and Vice-President of the Canadian Academy of Pain Management.
Michael G. DeGroote Pain Clinic, Hamilton Health Sciences, Hamilton, Ontario, Canada

Notes

Correspondence should be addressed to Dr. Eleni G. Hapidou at Michael G. DeGroote Pain Clinic, McMaster University Medical Centre, Hamilton Health Sciences, 1200 Main Street West, Hamilton, Ontario, Canada, L8N 3Z5. Telephone: 905-521-2100 ext. 77492. Email: [email protected]

Contributors

Conceptualization: GK Tippin and EG Hapidou
Methodology: F Bishay and EGHapidou
Software: EG Hapidou
Validation: F Bishay
Formal Analysis: F Bishay
Investigation: F Bishay and EG Hapidou
Data Curation: E Hapidou
Writing — Original Draft: F Bishay and EG Hapidou
Writing — Review & Editing: F Bishay, EG Hapidou, GK Tippin, and A Fransson
Visualization: F Bishay
Supervision: EG Hapidou
Project Administration: EG Hapidou
Funding Acquisition: EG Hapidou

Competing Interests

The authors have nothing to disclose.

Funding

This article received funding from the Chronic Pain Network through the Strategy for Patient Oriented Research (SPOR) (reference SCA-145102), and the Chronic Pain Center of Excellence for Canadian Veterans (CPCoE).

Ethics Approval

This study was approved by the Hamilton Integrated Research Board, Hamilton, Ontario, Canada, on July 12, 2021.

Informed Consent

N/A

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Journal of Military, Veteran and Family Health 2023 9:4, 50-62

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