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Abstract: Multidisciplinary treatment programs for chronic pain typically emphasize the importance
of decreasing maladaptive and encouraging adaptive coping responses. The Chronic Pain Coping
Inventory (CPCI), developed to assess coping strategies targeted for change in multidisciplinary pain
treatment, is a 64-item instrument that contains 8 subscales: Guarding, Resting, Asking for Assistance,
Relaxation, Task Persistence, Exercising/Stretching, Coping Self-Statements, and Seeking Social Sup-
port. A previous validation study with 210 patients in a Canadian academic hospital setting supported
an 8-factor structure for the CPCI. The current study was undertaken to validate the CPCI among 564
veterans with a more extended history of chronic pain. Patients completed the study questionnaires
before multidisciplinary treatment. A confirmatory factor analysis was used to examine the factor
structure of the 64-item CPCI. A series of hierarchical multiple regression analyses were performed
with depression, pain interference, general activity level, disability, and pain severity as the criterion
variables and the 8 CPCI factors as the predictor variables, controlling for pain severity and demo-
graphic variables. The confirmatory factor analysis results strongly supported an 8-factor model, and
the regression analyses supported the predictive validity of the CPCI scales, as indicated by their
association with measures of patient adjustment to chronic pain.
Perspective: This article validated the 8-factor structure of the CPCI by using a confirmatory factor
analysis and a series of linear regressions. The results support the applicability and utility of the CPCI
in a heterogeneous population of veterans with severe chronic pain treated in a tertiary teaching
hospital. The CPCI provides an important clinical and research tool for the assessment of behavioral
pain coping strategies that might have an impact on patient outcomes.
Key words: Coping with chronic pain, behavioral assessment instrument, validation of CPCI.
A
cognitive-behavioral model of chronic pain em- focused responses directed at regulating emotional re-
phasizes the importance of an individual’s at- actions to the problem.34 Coping responses also can be
tempts to cope with pain and pain-related issues considered adaptive or maladaptive, depending on the
or problems. Coping has been defined as “ѧconstantly usual outcome of the coping behavior, cognition, or
changing cognitive and behavioral efforts to manage emotion.
specific external and/or internal demands that are ap- Multidisciplinary treatment programs for chronic pain
praised as taxing, or exceeding the resources of the per- typically emphasize the importance of stopping the use
son.”34 Coping is an ongoing process that includes ap- of maladaptive and teaching and encouraging the use of
praisals of a demand or stressor; cognitive, behavioral, adaptive coping responses.37,48 Certain coping re-
and emotional coping responses; and subsequent reap- sponses, such as task persistence, have been associated
praisals of the demand. Most individuals view pain and with better physical and psychological functioning
its impact as stressful and cope according to their unique among individuals with chronic pain, whereas other cop-
history, personality, beliefs, biologic characteristics, and ing responses, such as pain-contingent resting and
guarding, have been correlated with impaired func-
social environment.8 Coping responses can be classified
tion.12,15,25,31,51
as problem-focused responses directed at changing or
Cross-sectional and longitudinal studies have demon-
managing the problem causing the stress or as emotion-
strated that coping responses are associated with
both short- and long-term adjustment to chronic
Received February 24, 2004; Revised September 17, 2004; Accepted Sep-
tember 25, 2004. pain.1,5,8,28,36,47,59 Pain coping responses have been
From the *Pain Section, Anesthesiology and Mental Health Care Line and shown to be related to measures of pain intensity, emo-
†Psychosocial Rehabilitation Program, VA Medical Center; ‡Department
of Anesthesiology and §Department of Family Medicine, Baylor College
tional distress, physical function, disability status, and
of Medicine; and 储Department of Symptom Research, The University of other psychosocial variables. For example, the use of
Texas M.D. Anderson Cancer Center, Houston, Texas; and ¶Department of
Rehabilitation Medicine, University of Washington, Seattle, Washington. multiple pain coping strategies has been correlated neg-
Address reprint requests to Gabriel Tan, PhD, ABPP, Veterans Affairs atively and significantly with disability14,38 and with psy-
Medical Center, Department of Anesthesiology, 2002 Holcombe Blvd chosocial dysfunction.23 A composite measure represent-
(116 MH), Houston, TX 77030. E-mail: tan.gabriel@med.va.gov
1526-5900/$30.00 ing cognitive coping responses (labeled “perceived
doi:10.1016/j.jpain.2004.09.006 control over pain and rational thinking”) has been sig-
in the current study was composed primarily of male were “Other,” and 9.9% did not respond to this item.
veterans with a more severe and extended history of Approximately half (50.2%) were married. Almost half
chronic pain (more than half of this population had been of the participants (48.0%) were already receiving dis-
on disability for more than 5 years, and a majority, 72%, ability compensation for a pain-related condition, and
reported pain at multiple sites). We sought to determine 58.0% indicated disability as a result of pain for more
whether the 8-factor structure originally proposed by than 5 years. Information about specific pain diagnosis
Jensen et al25 and subsequently supported by Had- was not collected, but breakdowns by primary pain sites
jistavropoulos et al17 would be confirmed by performing were as follows: back (39.0%), limbs (32.0%), neck/shoul-
a confirmatory factor analysis in a new sample of pa- ders (19.0%), head (6.0%), and “all over” (4.0%). Fur-
tients with chronic pain and also determine how the fac- thermore, 72% of the patients reported that they had
tor scores relate to patient adjustment. pain at multiple sites.
A secondary but equally important reason for under- To evaluate possible nonresponse bias, we collected
taking this study was to underscore the importance of demographic and disability information on all patients
assessing the behavioral domain of coping in addition to referred between January 1996 and December 1996. In-
cognitive coping strategies. Coping with pain depends formation was obtained on 94% of the patients and re-
on what people do as well as what they think. Pain man-
sulted in a sample of 126 responders and 168 nonre-
agement programs teach and encourage changes in
sponders. The responders and nonresponders did not
both thoughts and behavior. A well-validated behavioral
differ with regard to age (mean, 54.5 and 53.9 years,
coping measure is, therefore, of immense importance,
respectively). There was also no significant difference in
given that measures of both cognitive and behavioral
gender (2 ⫽ 1.92, not significant), marital status (2 ⫽
responses to pain are needed to guide interventions.
0.03, not significant), or disability status (ie, receiving no
Limiting coping assessment to just one potentially limits
disability, service-connected disability, or non-service-
information needed to guide treatment and therefore
connected disability) (2 ⫽ 0.68, not significant).
might ultimately limit treatment efficacy.
Methods Measures
Participants CPCI
The sample was obtained from the population of pa- The CPCI has 65 items that measure 11 coping strategies
tients with chronic noncancer pain referred to the Inte- that patients might use to cope with or manage chronic
grated Pain Management Program (IPMP) of the Hous- pain.25 The CPCI was specifically developed to assess many
ton VA Medical Center, a tertiary teaching hospital. This of the coping strategies targeted for change (either to be
is the same sample used in a previous study comparing encouraged or discouraged) in multidisciplinary treatment
CPCI and CSQ responses.51 The IPMP is a multidisciplinary of chronic pain.25 The strategies assessed include illness-
outpatient pain assessment, consulting, and treatment focused strategies (Guarding, Resting, Asking for Assis-
program that receives referrals from surgical, medical, tance, Opioid Medication Use, Nonsteroidal Medication
and psychiatric departments within the medical center. Use, Sedative-Hypnotic Medication Use), wellness-focused
Patients referred to the IPMP typically have an extended
strategies (Relaxation, Task Persistence, Exercise/Stretch,
history of chronic pain and have received prior treat-
Coping Self-Statements), and the strategy of Seeking Social
ments for pain. Patients were required to complete a
Support.
packet of self-report questionnaires before initial IPMP
In the initial validation and cross-validation studies,25
assessment. The questionnaire packet was mailed to pa-
each of the CPCI scales demonstrated adequate to excel-
tients with a cover letter explaining that the question-
lent test-retest stability (ranging from .65 to .90). In ad-
naires were to be used primarily for clinical purposes, but
dition, the internal consistency of the multiple-item (ie,
the data might also be used for program evaluation and
research. Before data were analyzed for the current not medication) scales ranged from .74 to .91. Validity
study, approval from the Institutional Review Board was was demonstrated by the scales’ ability to predict
obtained. Of the 1265 packets mailed from 1995 through spouse-rated patient functioning. In particular, patient-
1998, 564 packets were returned, with a return rate of reported use of Guarding, Resting, Asking for Assistance,
44.6%. Thus, slightly less than half of all patients referred and Sedative-Hypnotic Medication Use demonstrated
to the IPMP followed through on their referral and com- moderate to strong associations (rs ⬎ .30 or ⬍ ⫺.30) with
pleted the necessary paperwork to receive services. spouse-rated patient disability, spouse-rated patient ac-
The demographic characteristics of the subject sample tivity level, or both. Less strong, but still substantial (rs
were reported in our previous study comparing CPCI and between .20 and .30 or ⫺.20 and ⫺.30), associations were
CSQ responses.51 The mean age of patients completing found between Coping Self-Statements and Seeking So-
the questionnaires was 50.8 years (SD, 11.4; range, 22 to cial Support and spouse-reported disability. For the cur-
82 years). Most (84.5%) had at least a high school educa- rent study, subscales relating to medication consumption
tion; 12% were college graduates. The majority of the were excluded because of difficulty getting accurate and
subjects were male (90.3%). Although most were white reliable self-reports on this measure from the subjects;
(62.4%), 22.6% were black, 4.6% were Hispanic, 0.5% therefore, only 8 of the 11 CPCI scales were used.
32 Validation of the Chronic Pain Coping Inventory
Measures of Function and Adjustment retest stability of 0.86.30 The General Activity Level scale
consists of 18 items representing household chores, out-
Measures of pain and functioning available for analysis
door work, activities away from home, and social activi-
included the Center for Epidemiological Studies Depres-
ties. The scale score is computed by averaging the scores
sion Scale (CES-D) to assess depression, the Roland-Morris
of these 4 activities. Scale scores range from 0 to 108,
Disability Questionnaire (RMDQ) to assess disability, the
with higher scores indicating higher levels of activities
Interference scale of the West Haven–Yale Multidimen-
engaged by the patients from self-report. In the original
sional Pain Inventory (WHYMPI) to assess the extent to
article,30 the Cronbach ␣ of the 4 individual activity scales
which pain interferes with the patient’s life, the General
ranged from .70 to .86; however, the ␣ for the total scale
Activity scale of the WHYMPI to assess the patient’s gen-
was not reported. A subsequent study reported an ␣ of
eral activity level, and the Pain Severity scale of the
.76 for the total general activity scale.4
WHYMPI.
CES-D. The CES-D was used as a measure of psycho-
logical functioning in this study. The CES-D was devel- Pain Severity
oped to assess the presence and severity of depressive Because pain severity could influence the predictors
symptoms in a general population. The CES-D includes 20 (CPCI scales) as well as the criterion measures of psycho-
items that are answered on a 4-point scale (0, rarely; 3, logical and physical functioning (depression, interfer-
most of the time), resulting in scores ranging from 0 to 60 ence, general activity level, and disability) in the study,
(higher scores indicating greater depressive symptoms). the Pain Severity subscale of the WHYMPI was used to
The CES-D has been widely used in pain research6,22,39 assess pain severity and was entered in the analyses to
and has adequate reliability and convergent validity.41 control for this potential confound. The Pain Severity
Criterion validity has also been established because the subscale consists of 3 items that assess both pain intensity
CES-D scores of depressed and nondepressed subjects and suffering. Subscale scores range from 0 to 18, with
have been found to be significantly different.41 higher scores indicating greater intensity and suffering.
RMDQ. The RMDQ is used to assess disability associ- The pain severity subscale has an internal consistency of
ated with chronic pain. The RMDQ, derived from the 0.72 and a test-retest stability of 0.82.30
Sickness Impact Profile, was originally developed to as-
sess disability associated with back pain.43 Items focus Data Analysis
almost exclusively on the physical dimensions of disabil- The confirmatory factor analysis was performed by us-
ity.9 Subjects indicate which, if any, of 24 statements ing version 8.30 of LISREL.26 The initial model was based
describe them today and are related to their pain (for on the 8-factor model obtained from a previous explor-
example, “I stay at home most of the time because of my atory factor analysis.17 Each of the 64 observed variables
pain”). Scores range from 0 to 24, with higher scores was assumed initially to be associated with the factor
indicating greater disability. variable having its largest factor loading from the Vari-
Chronic pain treatment centers have found that the max rotation result of exploratory factor analysis. Thus
RMDQ is simple to use and provides a great deal of useful each observed variable was assumed initially to be asso-
clinical information about patients’ disability.60 Research ciated with 1 and only 1 of the 8 factor variables,
has supported the validity and reliability of the scale for whereas each factor variable was assumed to be associ-
assessing disability among persons with mixed chronic ated with the observed variables having their largest fac-
pain problems23 as well as low back pain.9,32 tor loadings. The correlation matrix between all 64 ob-
WHYMPI. The WHYMPI30 is a 56-item measure that served variables served as input data to the analysis. The
assesses the impact of pain on the patient’s life, the pa- factor variables were specified as standardized so that
tient’s view of how significant others respond to their the covariance matrix among factor variables was esti-
communication of pain, and the patient’s general activ- mated with the restriction of having 1’s on the diagonal
ity level. The validity and reliability of the WHYMPI have and correlation coefficients on the off-diagonal ele-
been well established.30 The validity of the WHYMPI has ments. In succeeding iterations of the model, changes
been further supported by the results of exploratory and were made on the basis of the sizes and t values of factor
confirmatory factor-analytic procedures.54 Two of the loadings () on the observed variables currently included
scales, Interference and General Activity Level, were in the model and on diagnostic indicators (modification
used as measures of function and adjustment for this indices) of improvements as indicated by decreases in
study. unexplained 2 values that could be realized by adding
The Interference scale of the WHYMPI consists of 11 additional loadings not included in the current model.
items that assess how pain has interfered with day-to- Output from each model included the matrix of factor
day activities and functioning, including the ability to loadings, the correlation matrix between factors,
work, to enjoy family, to participate in social and recre- the correlation matrix between measurement errors,
ational activities, and to perform household chores.30 squared multiple correlations between observed vari-
Scale scores range from 0 to 66, with higher scores indi- ables, various measures of goodness of fit and modifica-
cating greater perceived interference over one’s daily tion indices. In addition, the output from each model
functioning. The Interference scale has been reported to contained the regression coefficients for calculating fac-
have an excellent internal consistency of 0.90 and a test- tor scores from values of the observed variables.
ORIGINAL REPORT/Tan et al 33
Factor scores were obtained by applying the factor score sional Pain Inventory–General Activity Level [MPIGL]),
regression coefficients to the rescaled input variables. Al- disability (RMDQ), and pain severity (Multidimensional
though there were regression coefficients for each factor Pain Inventory–Pain Severity [MPIPS]) scales (Table 2). It is
on all 64 variables, only those coefficients associated with important to note that the mean CES-D score of 28.29 is
variables in the model for each factor were actually used, as substantially above the cutoff score of 23 for probable
is customary in exploratory factor analysis. The difference is depression as suggested by Husaini et al21 and larger
that factor scores from exploratory factor analysis used unit than that of a sample of persons with chronic pain before
weights, whereas factor scores from confirmatory factor multidisciplinary pain treatment (mean, 25.11; SD,
analysis used weights that were approximately propor- 12.86).24 Disability scores in this sample (mean, 16.32; SD,
tional to the factor loadings. 4.91) are similar to those of a chronic pain sample before
multidisciplinary pain treatment (mean, 15.10; SD, 4.94)
but significantly higher than the postmultidisciplinary
Results pain treatment scores from this same sample (mean,
9.12; SD, 5.70; P ⬍ .01).24 Finally, pain severity in this
Factor Analysis of the CPCI
sample (mean, 5.10; SD, .86) is significantly higher than
The initial confirmatory factor analysis model provided
the original published data from a heterogeneous
strong support for the exploratory factor analysis model
chronic pain population at the University of Pittsburgh
conducted by the Canadian researchers.17 Loadings of
(mean, 4.53; SD, 1.04; t ⫽ 8.76; P ⬍. 001) but lower than
the 8 factors on the 64 variables were essentially compa-
a sample of patients with chronic pain about to enter
rable in magnitude to those obtained previously for
multidisciplinary pain treatment (mean, 6.15; SD, 1.51; P
those associations assumed to exist. However, the modi-
⬍ .001).24 Taken as a whole, our sample appears to re-
fication indices, along with magnitudes of the estimated
port pain severity, depressive symptoms, and disability at
loadings, indicated that improvements could be made in
least as great as, and perhaps greater than, other sam-
the initial and succeeding confirmatory factor analysis
ples of patients with chronic pain that were available for
models, either by adding loadings not part of the current
comparison.
model or by eliminating loadings considered to be too
weak for inclusion in the model. The results of the final
model of the confirmatory facto analysis are shown in Intercorrelations of Empirically Derived
Table 1. CPCI Factors
As a measure of similarity between the initial explor- A correlation matrix was computed to examine the
atory factors and those derived from confirmatory factor relationships among the empirically derived CPCI factors
analysis, we computed the correlation between the 2 (based on outcome from the confirmatory factor analy-
sets of factors when applied to our input data, with the sis). As can be seen in Table 3, there are a number of
following results: statistically significant correlations among the CPCI fac-
Factor: Exercise/Stretch, Coping Self-Statements, Guard- tors, and the Pearson product-moment correlation coef-
ing, Seeking Social Support, Task Persistence, Relaxation, ficients tended to be in the low to moderate range.
Asking for Assistance, Resting
Correlation: 0.993, 0.990, 0.979, 0.994, 0.996, 0.937, Correlations between Empirically
0.999, 0.995 Derived CPCI Scales and Criterion
This analysis, showing very high correlations be- Variables
tween factor scores calculated from either the explor-
The relation between the empirically derived CPCI
atory or confirmatory factor analysis, provided ratio-
scales and the criterion variables of depression (CES-D),
nale for using either the unit weights (exploratory) or
pain interference (MPIIF), general activity level (MPIGL),
factor regression coefficients (confirmatory) when es-
disability (RMDQ), and pain severity (MPIPS) were initially
timating factor scores and also showed that it is not
examined via zero-order correlations, yielding Pearson
necessary to use all variables when calculating values
product-moment correlation coefficients (Table 4). Be-
for each factor because the factor regression coeffi-
cause of the large number of correlation coefficients
cients not used in the calculations were all negligible
computed and examined for these analyses, the ␣ level
in size and would have had minimal effect on the ac-
was set at P less than .01 to help control for the possibility
tual scores. Because of this finding, the tables to follow
of Type I error when interpreting these findings.24 As can
were based on unit weights rather than factor regres-
be seen in Table 4, depression had significant, positive
sion coefficients for ease of comparisons to the origi-
correlations with the Guarding, Asking for Assistance,
nal CPCI validation studies.
and Resting factors and a significant, negative correla-
tion with the Coping Self-Statements and Task Persis-
Descriptive Statistics for Primary tence factors. Pain interference was positively correlated
Variables with Guarding, Asking for Assistance, and Resting and
Means, SDs, and ranges were computed for the empir- negatively correlated with Task Persistence.
ically derived CPCI factors and the depression (CES-D), Six of the factors were significantly correlated with
pain interference (Multidimensional Pain Inventory–Pain general level of activity: Exercise/Stretch, Task Persis-
Interference [MPIIF]), general activity level (Multidimen- tence, and Seeking Social Support had positive associa-
34 Validation of the Chronic Pain Coping Inventory
Table 1. Continued
FACTORS
Abbreviations: EXE, Exercise/Stretch; COP, Coping Self-Statements; GUA, Guarding; SEE, Seeking Social Support; TAS, Task Persistence; REL, Relaxation; ASK,
Asking for Assistance; RES, Resting.
tions, whereas Guarding, Asking for Assistance, and Rest- R2), which ranged from 10.50% for pain severity to
ing had negative associations. Disability was positively 40.70% for disability (P ⬍ .001 in all models). Further-
correlated with Guarding, Seeking Social Support, Ask- more, the addition of the CPCI factors in the last step in
ing for Assistance, and Resting and negatively correlated each of the equations yielded a statistically significant
with Task Persistence. Finally, pain severity had signifi- increase in R2, ranging from 9.80% for depression to
cant, positive correlations with Guarding, Asking for As- 23.20% for disability (P ⬍ .001 in all models). In each
sistance, and Resting and a negative correlation with regression model, the CPCI factors accounted for unique
Task Persistence. variance in the criterion variable, above and beyond
In general, the correlations between the CPCI factors what is already accounted for by the control variables.
and the dependent measures were in the expected direc- Table 6 presents the standardized, partial regression
tions, assuming that the CPCI Task Persistence, Exercise/ coefficients () for all predictor variables in the final re-
Stretch, and Coping Self-Statements scales assess “adap- gression equations. The  indicates the nature of the
tive” coping responses, and the CPCI Guarding, Resting, relationship between the predictor and criterion vari-
and Asking for Assistance assess “maladaptive” coping ables, specifically the association between each predictor
responses. variable and the criterion when all other predictor vari-
ables are controlled.
Multiple Regression Analyses With regard to depression (CES-D), the Resting factor
To explore the ability of the empirically derived CPCI fac- was found to be a significant, positive predictor, whereas
tors to predict important pain-related outcomes, a series of Task Persistence was found to be a negative predictor.
hierarchical multiple regression analyses were conducted Among the control variables, pain severity was a positive
with depression (CES-D), pain interference (MPIIF), general predictor, and age was a negative predictor, when other
activity level (MPIGL), disability (RMDQ), and pain severity variables are taken into account. For pain interference,
(MPIPS) as the criterion variables and the 8 CPCI factors the Guarding and Resting factors were significant, posi-
(Guarding, Resting, Asking for Assistance, Relaxation, Task tive predictors, and Task Persistence was a negative pre-
Persistence, Exercise/Stretch, Seeking Social Support, Cop- dictor. Among the control variables, pain severity was
ing Self-Statements) as the primary predictor variables (Ta- found to be a significant, positive predictor of pain in-
ble 5). Pain severity (when not used as a criterion variable) terference. Furthermore, the size of the  (.37) and the
was entered in the first step. Age, sex, and education were significance level (P ⬍ .001) suggest that pain severity
entered in the second step. We controlled for these vari- was the most powerful predictor of pain interference.
ables because they often correlate with adjustment, as well With respect to general activity level, Task Persistence
as coping strategy use. The CPCI factors were entered last and Seeking Social Support were significant, positive
into the equations to determine whether they accounted predictors, whereas Guarding was a negative predictor.
for unique variance in the criterion variables, above and Pain severity was the only control variable to signifi-
beyond what is already accounted for by pain severity and cantly predict general activity level. Regarding disability,
the demographic variables. Again, because of the large Guarding and Asking for Assistance were significant,
number of analyses, we set the ␣ level at P less than .01 to positive predictors, whereas Task Persistence was found
control for ␣ inflation associated with multiple analyses.24 to be a negative predictor. Among the control variables,
As can been seen in Table 5, in each regression model, pain severity was a positive predictor. Finally, when pain
the control variables and the CPCI factors as a group severity served as the dependent variable, Resting was
accounted for a statistically significant amount of vari- found to be a positive predictor. No demographic vari-
ance in the criterion variable, as indicated by the ad- ables were significant predictors of pain severity.
justed coefficient of multiple determination (adjusted In summary, the results of the regression analyses indi-
36 Validation of the Chronic Pain Coping Inventory
Means, SDs, and Ranges for Empirically Derived CPCI Factors, CES-D, MPIIF, MPIGL,
Table 2.
RMDQ, and MPIPS
SCALE MEAN SD RANGE N
CPCI factors
Exercise/Stretch 2.20 1.96 0-7 508
Coping Self-Statements 3.33 1.96 0-7 508
Guarding 4.43 1.63 0-7 510
Seeking Social Support 2.35 1.68 0-7 509
Task Persistence 3.13 1.92 0-7 509
Relaxation 2.20 1.68 0-7 508
Asking for Assistance 2.82 2.24 0-7 508
Resting 4.92 1.84 0-7 510
CES-D 28.29 12.14 0-60 526
MPIIF 5.04 .89 1.33-6.00 564
MPIGL 1.64 .98 0-5.19 561
RMDQ 16.32 4.91 1-24 561
MPIPS 5.10 .86 1-6 564
Abbreviations: EXE, Exercise/Stretch; COP, Coping Self-Statements; GUA, Guarding; SEE, Seeking Social Support; TAS, Task Persistence; REL, Relaxation; ASK,
Asking for Assistance; RES, Resting.
*P ⬍ .001.
†P ⬍ .01.
cate that as a group, the empirically derived CPCI factors tion Medical Center. The factor structure of the original 8
accounted for unique variance in depression, pain inter- CPCI subscales was generally confirmed. A confirmatory
ference, general activity level, disability, and pain sever- factor analysis strongly supported the 8-factor model. Of
ity above and beyond what is accounted for by the de- the original 64 items in the 8 subscales, only 2 items (#40
mographic variables (age, sex, education) and pain and #64) did not fit in the original Guarding subscale and
severity (when inserted as a predictor variable). Several needed to be moved to the Resting subscale. The factor
CPCI factors were found to be significant predictors of model contained only 4 loadings between 0.30 and 0.40,
each of the criterion variables. The Coping Self- with the remaining loadings above 0.40.
Statements, Relaxation, and Exercise/Stretch factors, The findings also support the predictive validity of the
however, were not significant predictors in any of the CPCI scales and were consistent with a cognitive-
models. Task Persistence was the most consistent predic- behavioral model of chronic pain that hypothesizes sig-
tor among the CPCI factors. Pain severity was a signifi- nificant associations between coping and functioning in
cant predictor in all models, which lends support to its persons with chronic pain. As predicted, the CPCI factor
inclusion as a control variable when assessing the predic-
scores were significantly related to a number of mea-
tive ability of the coping scales. Finally, with the excep-
sures of patient adjustment to chronic pain; with the
tion of age predicting depression, the demographic vari-
exception of the Relaxation factor, all of the factors were
ables were not significant predictors in any of the
significantly correlated with at least one of the depen-
models.
dent variables. Although the significant correlations
were generally modest and also variable across the cop-
Discussion ing factors, not all coping factors are necessarily equally
The purpose of the present study was to confirm the important to the management of chronic pain. In fact,
factor structure and validity of the CPCI in a population one of the goals of the CPCI is to identify those coping
of patients with chronic pain in a Veterans Administra- strategies that are most important to patient function-
ORIGINAL REPORT/Tan et al 37
Table 4. Correlations of the Empirically Derived CPCI Factors with CES-D, MPIIF, MPIGL, RMDQ,
MPIPS
FACTOR CES-D MPIIF MPIGL RMDQ MPIPS
*P ⬍.01.
†P ⬍ .001.
*P ⬍ .001.
†P ⬍ .01.
ing. The current validity data demonstrate that the CPCI The empirically derived CPCI factors also demonstrated
is useful for this purpose, given the variability found in impressive predictive ability. After controlling for demo-
the correlates of the CPCI factor scores. The zero-order graphic variables and pain intensity, the CPCI factors ac-
correlations between the CPCI factors and self-reported counted for a significant amount of variance in patients’
adjustment to chronic pain suggest that Task Persistence, self-reported depression, disability, pain interference,
Exercise/Stretch, and Coping Self-Statements are adap- and general activity level. The CPCI factors also made an
tive coping responses, and that Guarding, Resting, and independent contribution to the prediction of pain se-
Asking for Assistance are maladaptive in this sample. The verity. The factors that were most highly associated with
2 remaining factors, Seeking Social Support and Relax- Disability, Pain Interference, and General Activity Level
ation, are less clear as to whether they are adaptive or explained 41.0%, 35.0%, and 28.0% of the variance, re-
maladaptive. Our results are generally consistent with spectively, in these variables. In a previous study of the
those from previous studies of the CPCI. For example, CPCI, the empirically derived factors also made signifi-
Jensen et al25 found that Guarding and Resting were cant contributions to the prediction of pain severity and
positively associated with depression and pain-related pain-related interference.17 However, unlike the find-
affective distress and negatively correlated with general ings of the previous research, this study did not find Re-
activity. Task Persistence demonstrated significant nega- laxation to be associated with emotional distress. In-
tive associations with depression and affective distress. stead, our finding suggests that Relaxation appears to be
38 Validation of the Chronic Pain Coping Inventory
Table 6. Standardized Regression Coefficients () for All Predictor Variables in the Final
Regression Equation
PREDICTOR VARIABLES CES-D MPIIF MPIGL RMDQ MPIPS
more adaptive, a finding more consistent with current cantly associated with Seeking Social Support and might
conception of the role of relaxation. We also found that represent a negative component of social support seek-
Asking for Assistance and Seeking Social Support were ing. In the regression models, the Asking for Assistance
not associated with less favorable adjustment to chronic strategy might have controlled for the negative aspect of
pain. social support and left the positive aspects of support
With regard to the individual CPCI factors in the that are associated with adaptation to chronic pain. Our
present study, Task Persistence was a significant predic- results emphasize the clinical importance of helping pa-
tor of depression, interference, activity, and disability. tients distinguish between the adaptive and maladap-
Guarding predicted all of the criterion variables except tive aspects of seeking social support.
depression and pain severity, and Resting predicted all of Given that our study design was cross-sectional and
the variables except disability and general activity level. correlational, it is not possible to draw causal conclusions
Asking for Assistance, Seeking Social Support, and Cop- from the findings. For example, we cannot determine
ing Self-Statements each predicted one criterion vari- whether the coping strategy of Task Persistence helps to
able. Overall, these results confirm the clinical impor- promote activity and prevent depression, disability, and
tance of teaching and reinforcing the coping strategy of pain-related interference. It is possible that patients who
Task Persistence and discouraging the regular use of are active, not depressed, and functioning relatively well
Guarding and Resting. The results suggest that Coping are more apt to develop and use Task Persistence as a
Self-Statements is a positive strategy, but this coping coping strategy. In addition, it should be noted that, as a
strategy was significantly associated with only one out- group, the 8 CPCI factors accounted for only 10% to 18%
come variable. Relaxation and Exercise/Stretch did not of the variance in each of the criterion variables, after
predict any outcome variable. controlling for pain severity and demographic variables.
The Seeking Social Support factor was a significant Given the difficulties associated with treating chronic
positive predictor of general activity level. These results pain, however, identifying coping strategies associated
suggest that Seeking Social Support is an adaptive cop- with positive outcomes is clinically meaningful, even if
ing strategy. In the zero-order correlations, however, the associations found are modest. Additional research is
Seeking Social Support was positively associated with dis- needed to identify other factors that help to predict pa-
ability. Our findings demonstrate the complicated na- tient outcomes. In particular, prospective longitudinal
ture of the association between Seeking Social Support and experimental studies are needed to assess patient
and functioning. The social support coping strategy is coping strategies and other potential predictors over
undoubtedly multidimensional and might include both time and to determine their causal relation to multiple
adaptive (eg, obtaining emotional support that en- outcome variables.
hances functioning) and maladaptive (eg, obtaining help Additional limitations of the current study include the
with tasks that the patient can perform) components. It unique characteristics of the patient sample and the reli-
is also possible that this strategy is adaptive, but that ance on self-report measures. Because our sample consisted
patients use it more when they experience greater dis- of primarily male veterans, we were not able to evaluate
ability or distress (eg, effective medications would be any possible gender differences. The results of recent stud-
used more often by people who are ill, thereby produc- ies suggest that men and women might differ somewhat in
ing a positive association between medication use and their preferred strategies for coping with chronic pain.8,58
illness, even though the medications are effective). In addition, the patients in our sample reported more se-
The Asking for Assistance coping strategy was signifi- vere pain, pain duration, depression, and disability than did
ORIGINAL REPORT/Tan et al 39
samples of patients with chronic pain from other pain for the reliability and validity of the CPCI for assessing
treatment settings. Also, only 45% of the eligible patients coping strategies important to chronic pain adjustment.
chose to participate in the study by returning the com- The findings of this study also provide additional evi-
pleted questionnaires. Although the responders did not dence for the utility of the CPCI by demonstrating that it
differ significantly from nonresponders on demographic is equally valid and reliable when used for pain sufferers
variables, they might have differed on other pain-related with a more chronic, severe, and extended history of
variables that were not assessed. Thus, the generalizability pain. Additional studies of the CPCI with other patient
of the current findings is limited. populations are needed to determine the generalizabil-
Despite the limitations of the current study, the find- ity of the current findings. Future research also should
ings provide additional support for the cognitive- investigate the relation of coping strategies to outcome
behavioral model of chronic pain, for the potential im- measures such as family function, employment status,
portance of coping in adjustment to chronic pain, and and utilization of health care services.
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