Predicting Readiness to Attend an Interdisciplinary Pain Management Program: What’s better for Clinical Decision-Making? Clinical Judgment or a Patient Self- Report Questionnaire?

Research Article

Austin J Anesthesia and Analgesia. 2017; 5(2): 1057.

Predicting Readiness to Attend an Interdisciplinary Pain Management Program: What’s better for Clinical Decision-Making? Clinical Judgment or a Patient Self- Report Questionnaire?

Hapidou EG1,2,3*, Mazzocato GL4 and Culig KM3

¹Michael G. De Groote Pain Clinic, Hamilton Health Sciences, Canada

²Psychology, Neuroscience, & Behaviour, McMaster University, Canada

³Bachelor of Health Sciences (Honours Program), McMaster University, Canada

4Occupational Therapy, Hamilton Health Sciences

*Corresponding author: Hapidou EG, Michael G. De Groote Pain Clinic, Hamilton Health Sciences, Canada

Received: August 04, 2017; Accepted: September 07, 2017; Published: September 14, 2017


Background: Chronic Pain (CP) can have a substantial negative impact on one’s life. Patients often seek Pain Management Programs (PMPs) as a means to treat their CP condition. The Michael G. DeGroote Pain Clinic, located in Hamilton, Ontario is a PMP that admits patients based on a variety of clinically important factors. Patients assessed are either recommended or not recommended into the program after consideration of these factors.

Aims: The objective of this study was to examine if readiness, as assessed by the Pain Stages of Change Questionnaire (PSOCQ), is associated with a clinical judgment of readiness in recommending a person into a PMP. Additionally, to investigate whether PSOCQ scores or clinician judgment predicted readiness to attend a PMP.

Methods: One-hundred and eight people were approached and recruited to this study. The 108 patients referred to the PMP in Ontario, were either recommended or not recommended into a PMP after completing an initial assessment. Associations between clinician rating, recommendation status and PSOCQ subscale scores were analyzed using independent t-tests, Pearson Correlation, and Stepwise Regression. We hypothesize that readiness assessed by the PSOCQ would be associated with clinical judgment of readiness in recommending a person into the PMP but that clinical judgment would be superior in predicting readiness to attend a PMP rather than the PSOCQ scores.

Results: Those recommended to the PMP had higher assessor ratings, lower pre-contemplation and higher contemplation scores. There were significant relationships between the clinician’s rating, pre-contemplation, contemplation, and recommendation status. Stepwise regression methods revealed that while there may be benefit to using questionnaire measures of readiness to change, clinical judgment was the best predictor for recommendation into the PMP.

Conclusions: Clinical judgment in the initial assessment process was superior in clinical decision-making regarding a patient’s readiness to attend a PMP, as compared to a self-report questionnaire.

Keywords: Chronic pain; Readiness; PSOCQ


Individuals who suffer from chronic pain (CP) vary in their readiness to change their approach in dealing with their pain. Readiness is defined as “the degree to which a person accepts personal responsibility for pain control, and the extent to which they are thinking about changing their behaviour to cope with their pain” [1]. According to the transtheoretical model of behaviour change, individuals are seen as progressing through a number of stages regarding decisions to change [2]. The idea of “stages of change” being applied to chronic pain management stimulated research by Kerns and colleagues [1,3], who sought to determine the relevance of readiness to change when considered with the multidisciplinary cognitive behavioural approach to pain management [4]. The pain “stages of change” model proposes that individuals vary in their readiness to adopt a self-management approach to chronic pain and that all CP patients can be categorized into one of four discrete stages of change: pre-contemplation, contemplation, action, and maintenance. The model also proposes that individually tailored treatment approaches can be implemented according to the stage of change that an individual belongs to.

As an example, those in earlier stages of change (i.e., precontemplation and contemplation) may benefit more from cognitive interventions including education about chronic pain. In comparison, those in later stages of change (i.e., action and maintenance) are more likely to benefit from skills training, relaxation training, exercise and relapse prevention strategies.

The Pain Stages of Change Questionnaire (PSOCQ) validly and reliably assesses readiness to change in chronic pain patients [3]. It measures four stages according to degree of readiness to adopt a self-management approach to chronic pain: 1) Pre-contemplation (Precont) is the belief that management of the pain problem is medical and should be the responsibility of medical professionals to alleviate; 2) Contemplation (Cont) is the consideration of adopting a self-management approach but reluctance to give up the pursuit of a medical solution; 3) Action is the beginning attempts to improve selfmanagement skills; and 4) Maintenance (Maint)is the commitment to pain self-management.

The use of a multidisciplinary pain management program has more recently been found to improve an individual’s readiness to change in self-regulating their chronic condition [4]. In particular, patients who underwent treatment in this PMP significantly lowered their Precont subscale scores, while significantly increasing their Action and Maint scores [5]. In addition, Kerns and Rosenberg [1] demonstrated the predictive ability of the PSOCQ in determining engagement in treatment. However, these researchers were not able to demonstrate the predictive ability of the PSOCQ in determining pain outcomes. The PSOCQ identifies the primary stage of change of a patient and can predict their completion of outpatient and inpatient cognitive behavioural programs [1,6,7] as well as improved coping [8]. Consistent with past studies, motivational readiness predicted treatment completion as well as functional rehabilitation outcomes in CP patients who experienced a motor vehicle accident [9]. Further, a recent study provided evidence for the tool’s cross-cultural reliability and validity in an Italian-speaking cohort [10]. Another study examined the influence of readiness to change in predicting treatment outcomes in an adolescent population [11]. From this exploration, the reliability and validity of the parent and adolescent adapted PSOCQ scale were demonstrated.

Recently, a study was conducted to investigate the psychometric properties of the PSOCQ scale in a pediatric CP population in order to provide further cross-validation of the subscale measures across diverse patient groups [12]. Results from this study indicate that the psychometric proprieties (e.g., internal consistency, testretest stability, and construct validity) were robust in this sample of patients. In another investigation, researchers attempted to observe if PSOCQ scores were a reliable predictor of completing treatment and were associated with treatment outcomes in a sample of 261 patients living with chronic non-malignant pain [13]. The authors reported the predictive value of the PSOCQ in determining which patients were more likely to complete treatment. In addition, the authors found that those who progressed through the stages of change, in contrast to those who did not progress or reverted, demonstrated significant improvement in function (measured by the SF-36 version 2), and mood outcomes (e.g., mood disturbance, measured by the SF-36 version 2 mental health subscale). Despite this, no significant improvements in pain were reported for those who progressed through the PSOCQ stages versus those that did not progress or regressed.

The Cont subscale of the PSOCQ has been found to be one of the predictors of functional outcome three months into treatment for chronic pain [14]. However, classification of patients based on scores on a single subscale has been criticized [15]. The PSOCQ has been used to identify subgroups (clusters) of individuals seeking treatment for chronic pain; subgroups differed according to scores on the Survey of Pain Attitudes but not in terms of demographics, pain or disability [16]. However, irrespective of which method is used to classify individuals into discrete stages or subgroups, the PSOCQ has been found to be insufficient in terms of determining inclusion or exclusion criteria for enrolment in a cognitive-behavioural program [6]. Moreover, researchers have questioned the external validity of the PSOCQ by showing that a self-efficacy measure was a better predictor of outcome than the PSOCQ [17]. In addition, others have found that adherence to therapist recommendations for practicing coping skills mediated readiness to change and goal accomplishment in a chronic pain management program [18]. It has also been suggested that while psychometric tools are valuable in assessment, they should not be considered a reliable substitute for the clinical interviewing process [19].

However, there is paucity of research in examining readiness to change in the context of clinical decision-making. This is much needed in light of the fact that many individuals either do not improve, or complete treatment unsuccessfully [20]. Dropout rates from cognitive-behavioural pain management programs can vary between 5% to 70% [21]. Therefore, there have been repeated calls to identify consistent and reliable pre-treatment patient indicators predictive of the success of chronic pain management programs. One such indicator may be readiness to change behaviour and adopting a self-management approach to pain.

Materials and Methods


A convenience sample of 108 adults (54 female) who were assessed in the PMP participated in this study. Table 1 lists the demographic variables of the participants. The majority of individuals in this sample sustained injuries in work-related or motor vehicle accidents, which acted as an antecedent to their CP condition. This cohort of patients had a variety of chronic pain problems, including generalized and regionalized body pain. The majority of participants were taking medications such as opioids, anti-depressants, antiinflammatories and sleep medications prior to assessment into the PMP. All participants provided written informed consent before participating in the PMP assessment and ongoing program research. Ethics approval was obtained by the Hamilton Integrated Research Ethics Board (HiREB) of Hamilton Health Sciences.