Over the past few months I’ve been using the Chronic Pain Acceptance Questionnaire (CPAQ-8) as part of a battery of questionnaires used at intake and outcome measures. Along with the CPAQ-8, we use the Tampa Scale for Kinesiophobia, the Depression Anxiety Stress Scale, the Pain Anxiety Symptoms Scale, the Pain Catastrophising Scale, Pain Self Efficacy Questionnaire, and Pain Disability Index.
The CPAQ-8 consists of two subscales: Pain Willingness and Activity Engagement. Together they measure “acceptance” or psychological flexibility associated with chronic pain.
Let me pull this apart a bit. Pain Willingness refers to how prepared a person might be to experience an increase in pain so they can get something important done. For example, I love to dance and I’m prepared to have an increase in pain when I dance (and afterwards) because of the buzz I get from the shimmy. We probably all willingly experience pain to get a flu jab, or to stand in a queue to get tickets to a really great concert, or to carry a child who is too tired to walk.
Activity Engagement refers to how actively involved a person is in activities that are important – things like getting on with life, taking care of responsibilities, making plans for life that don’t include getting rid of pain. I’m sure anyone who has worked with people who have chronic pain will have seen people who have put life on hold for sometimes years in their search for something to get rid of pain, who have turned the search for pain reduction into their reason for living.
I wanted to include this measure because of the mounting evidence that acceptance of pain has a strong relationship with things like mood, disability, confidence and so on, so it’s been really interesting to begin to use this tool clinically.
Before I proceed with the following example, please remember that case vignettes I share are based on real people with details changed to protect privacy!
Let’s call him Wayne. Wayne has had a major mountain bike crash resulting in multiple fractures of his pelvis, lower leg as well as his right arm and shoulder. He’s had his pain for four years, and has had several surgeries to firstly fixate his lower leg fractures, then to remove the pins and plate, then to remove the pins that were inadvertently left in place. His main pain is his lower limb and he has been told it is complex regional pain syndrome – although technically it doesn’t have all the hallmarks of full-blown CRPS. Whatever the diagnosis, he now has allodynia (pain on what is normally nonpainful stimuli – for him, it’s pain on the touch of fabric, when the breeze blows over his leg, water when showering etc), he has hyperalgesia (increased pain to what is normally painful input – when he bumps his leg, if he scrapes it), his leg aches at rest, and gets more painful when he walks for any further than a few meters, and he finds walking over rough ground is next to impossible.
Wayne has seen a lot of clinicians for his pain, including his surgeon, anaesthetists who have tried various infusions, physicians who have tried medications of all sorts, physiotherapists who have used TENS, mirrorbox, and functional restoration. Wayne is not happy. Nothing has helped. He’d really like to have an amputation because he’s talked to other guys with similar injuries who have had an amputation who say they can now “get on with life”.
Wayne feels like his life has stopped since his accident. He’s gone from being more than busy running his own business, involved in adventure sports, being in a good relationship, planning for children – to waiting, being dependent on compensation payments, and unemployed with no sporting outlets, and his relationship is foundering.
When I reviewed Wayne’s questionnaire responses, several things stood out: his DASS wasn’t elevated suggesting he doesn’t view himself as low in mood or stressed or anxious; his overall PCS was in the average range – but his Helplessness subscale in that questionnaire was very high, so while he may not feel that he catastrophises, he does acknowledge feeling there is little he can do about his pain. His Pain Self Efficacy Questionnaire was slightly lower than average, so maybe he didn’t feel particularly confident about doing things despite pain; and on three of the subscales of the PASS his scores were below average, with only his Cognitive Anxiety subscale being elevated – but it was very high, so maybe he finds it difficult to “think straight” when his pain levels are intense.
On the CPAQ-8, his Pain Willingness was very low, in the 25th percentile. At the same time, his Activity Engagement was in the average range at around 44th percentile. These two measures combined tell me that Wayne’s not yet ready to accept living a different life from the one he’d pursued before his mountain bike smash. His main focus is on not having pain while his activities are aimed at finding ways to avoid having pain.
Where do we go with this? I’d like to start working on whether his current strategies are working to give him the life he really wants. What he seemed to value before his crash was being outdoors, having a sporting lifestyle, getting into adrenaline-pumping high adventure living. Is trying to avoid pain helping him live his values? Is he willing to bring his pain with him while he does some of the things he loved? Can he make room for his pain to be present as he takes steps towards the life he used to have? Can I, as a clinician, help him recognise how his old skills and bravery might help him live well despite his pain?
Fish, R., McGuire, B., Hogan, M., Morrison, T., & Stewart, I. (2010). Validation of the Chronic Pain Acceptance Questionnaire (CPAQ) in an Internet sample and development and preliminary validation of the CPAQ-8 Pain, 149 (3), 435-443 DOI: 10.1016/j.pain.2009.12.016