Choosing chronic pain questionnaires

ResearchBlogging.orgChoosing a set of questionnaires for an assessment battery can be a task fraught with all kinds of traps, because if there is one thing bound to get clinical tongues flapping, it’s the idea that their favourite questionnaire will be left out of the mix! And to complicate matters for us Southern Hemispherians, most of the research into normative data for questionnaires is North American, so it can be a long, quite tedious and epic job to arrive at a set that covers all the basic domains, doesn’t give the client questionnaire-fatigue, and uses psychometrically-sound  instruments.

At the Centre where I work, the set of questionnaires has just been reviewed and, working with a number of clinicians from around the country, we have arrived at a set that seems to be a reasonably workable group.  I’ll take you through the process shortly.

I should quickly put in here that we ask people to complete the set of questionnaires before they attend for their appointment (actually, we have just moved to only making appointments for people who have returned their questionnaires).  This means the scores are available before we start assessing, and we’re therefore able to identify areas that need to be targeted and enquired about specifically.

First up – why use questionnaires anyway? Well, they are most definitely NOT X-rays of the mind, so don’t rely on a pen and paper questionnaire to tell you anything that the person wouldn’t tell you anyway.  What questionnaires do is:

  • organise the information in a way that helps to make sense of it
  • allow the client to tell you things without the demand characteristics of sitting in front of you
  • cut down the time and volume of information needed
  • allow you to ask the same questions in the same way at different times – so you can monitor progress
  • enable collecting information from lots of people, so it’s possible to compare the response from an individual with the responses from a large number of people.  This means you can determine how close to the ‘average’ this person’s responses are.

BUT, a questionnaire won’t be an awful lot of use if you don’t know what it’s measuring, if what it’s measuring isn’t relevant, if it’s not reliable – and if you use norms, if the reference group doesn’t have similar characteristics to the kind of patient you’re working with.

End of that little diatribe!

The next question is what do you want to find out? While there is little real agreement on the specific questionnaire under each domain, there is some agreement among researchers at least about the domains that are thought to be important.  Clinicians’ opinions about relevant domains are not well-represented in the literature, unfortunately, so it’s a little bit of a guess to determine what is and isn’t useful to include.

From a researcher’s point of view, the IMMPACT set of recommendations is a good starting point.  Unfortunately, it’s quite demanding for day-to-day clinical use, although the instruments included in the recommendations are, naturally, of excellent quality.

The domains our team came up with were (in no particular order):

Mood and anxiety – depression, anxiety and pain-specific anxiety were chosen because of their importance to outcomes, and the need to treat psychopathology

Catastrophising – because this is thought to be one of the most important aspects of cognition that needs to be addressed

Pain-related anxiety and avoidance – because this appears to be one of the strongest predictors of ongoing disability

Acceptance – this domain has been emerging as an increasingly important treatment process variable, and may be a target for intervention

Pain location and intensity – yes, we do ask, just in case you wondered!

Pain self efficacy – again, this seems to be an important process variable, and a target for treatment.  It’s also associated with higher levels of disability.

Pain-related disability – this is, hopefully, one of our most important outcomes, so we measure this more than once.

The specific instruments we have come up with is the subject of my next post!

There is some debate about the purpose of pre-treatment questionnaires (and assessment, to be honest!).  I’ve used the MPI (the link takes you to a pdf copy – but please don’t just go and use it without reading about it in the original article or in review articles!), which has been used to profile patients into treatment groups; I’ve also used a set of questionnaires that lacks this profiling capability.  To be perfectly honest, I would love to think there is a really sound treatment profiling instrument, but I don’t think we’re there yet.  The MPI has some very good characteristics, and it certainly helped determine the most appropriate treatment stream in the setting where I used it, but it lacks a strong theoretical model to underpin it, and with the most recent research developments in acceptance and self efficacy and catastrophising, I wonder whether it’s The Best Questionnaire Ever.

More on this fascinating topic tomorrow – next up, the instruments we’ve chosen, and some of the reasoning behind our choices; also – what else to think about when selecting questionnaires.

Dworkin, R. H., Turk, D. C., Farrar, J. T., Haythornthwaite, J. A., Jensen, M. P., Katz, N. P., et al. (2005). Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain, 113(1-2), 9-19.

DWORKIN, R., TURK, D., WYRWICH, K., BEATON, D., CLEELAND, C., FARRAR, J., HAYTHORNTHWAITE, J., JENSEN, M., KERNS, R., & ADER, D. (2008). Interpreting the Clinical Importance of Treatment Outcomes in Chronic Pain Clinical Trials: IMMPACT Recommendations The Journal of Pain, 9 (2), 105-121 DOI: 10.1016/j.jpain.2007.09.005

Salaffi, F., Sarzi-Puttini, P., Ciapetti, A., & Atzeni, F. (2009). Assessment instruments for patients with fibromyalgia: properties, applications and interpretation. Clinical & Experimental Rheumatology, 27(5 Suppl 56), S92-105.

Turk, D. C., Dworkin, R. H., Revicki, D., Harding, G., Burke, L. B., Cella, D., et al. (2008). Identifying important outcome domains for chronic pain clinical trials: an IMMPACT survey of people with pain.  Pain, 137(2), 276-285.

Turk, D. C., Dworkin, R. H., McDermott, M. P., Bellamy, N., Burke, L. B., Chandler, J. M., et al. (2008). Analyzing multiple endpoints in clinical trials of pain treatments: IMMPACT recommendations. Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials. Pain, 139(3), 485-493.

Turk, D. C., Dworkin, R. H., Allen, R. R., Bellamy, N., Brandenburg, N., Carr, D. B., et al. (2003). Core outcome domains for chronic pain clinical trials: IMMPACT recommendations. Pain, 106(3), 337-345.

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