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The SPADE Symptom Cluster in Primary Care Patients With Chronic Pain

Davis, Lorie L. MSN, RN, OCN; Kroenke, Kurt MD; Monahan, Patrick PhD; Kean, Jacob PhD; Stump, Timothy E. MA

The Clinical Journal of Pain: May 2016 - Volume 32 - Issue 5 - p 388–393
doi: 10.1097/AJP.0000000000000286
Original Articles

Objectives: Sleep disturbance, pain, anxiety, depression, and low energy/fatigue, the SPADE pentad, are the most prevalent and co-occurring symptoms in the general population and clinical practice. Co-occurrence of SPADE symptoms may produce additive impairment and negatively affect treatment response, potentially undermining patients’ health and functioning. The purpose of this paper is to determine: (1) prevalence and comorbidity (ie, clustering) of SPADE symptoms; (2) internal reliability and construct validity of a composite SPADE symptom score derived from the Patient-Reported Outcomes Measurement Information System (PROMIS) measures; and (3) whether improvement in somatic symptom burden represented by a composite score predicted subsequent measures of functional status at 3 and 12 months follow-up.

Methods: Secondary analysis of data from the Stepped Care to Optimize Pain care Effectiveness study, a randomized trial of a collaborative care intervention for Veterans with chronic pain.

Results: Most patients had multiple SPADE symptoms; only 9.6% of patients were monosymptomatic. The composite PROMIS symptom score had good internal reliability (Cronbach’s alpha=0.86) and construct validity and strongly correlated with multiple measures of functional status; improvement in the composite score significantly correlated with higher scores for 5 of 6 functional status outcomes. The standardized error of measurement (SEM) for the composite T-score was 2.84, suggesting a 3-point difference in an individual’s composite score may be clinically meaningful.

Discussion: Brief PROMIS measures may be useful in evaluating SPADE symptoms and overall symptom burden. Because symptom burden may predict functional status outcomes, better identification and management of comorbid symptoms may be warranted.

*Indiana University School of Nursing

Department of Medicine, Indiana University School of Medicine

VA HSR&D Center for Health Information and Communication, Roudebush VA Medical Center

§Regenstrief Institute Inc.

Department of Biostatistics, Indiana University, Indianapolis, IN

Department of Veterans Affairs Health Services Research and Development Merit Review award to Dr Kroenke (IIR 07-119); VA Career Development Award to Dr Kean (CDA IK2RX000879); National Institute of Arthritis and Musculoskeletal and Skin Diseases R01 award to Dr Monahan (R01 AR064081); and a Doctoral Degree Scholarship in Cancer Nursing from the American Cancer Society (DSCN-14-080-01-SCN); a Predoctoral Fellowship from the Behavioral Cooperative Oncology Group, Walther Program for Cancer Care Research, Indianapolis, IN; a Research Doctorate Scholarship from the Oncology Nursing Society Foundation, Pittsburgh, PA; and Research Incentive Funding from the Indiana University School of Nursing, Indianapolis, IN, awarded to Ms. Davis. Identifier: NCT00926588.

The authors declare no conflict of interest.

Reprints: Lorie L. Davis, MSN, RN, OCN, Indiana University School of Nursing, 1111 Middle Drive, NU 338, Indianapolis, IN 46202 (e-mail:

Received April 20, 2015

Received in revised form August 31, 2015

Accepted July 29, 2015

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