3.2. Round 1
In round 1, 8 questionnaires were proposed for fear of movement, 11 for coping, 5 for self-efficacy, and 6 for catastrophizing. An overview of all suggested questionnaires is provided in Table 2. Nil (catastrophizing) to 10 (coping) panel members did not consider themselves an expert for a particular factor and therefore omitted the domain (Table 2).
3.3. Round 2
The response rate for round 2 was 72%. The percentage of scores that were higher than 7 on the 11-item Numeric Rating Scale for suitability for each questionnaire is presented in Table 2. The top 5 questionnaires were retained for round 3 for fear of movement and coping. For self-efficacy and catastrophizing, a top 3 and top 2 were retained, respectively, because less than 50% of experts graded the other questionnaires with a score higher than 7 on the suitability rating scale (Table 2).
3.4. Round 3
The response rate for round 3 was 69%. For each psychosocial factor, consensus was reached for 2 or 3 questionnaires, which could be recommended for use (Table 3).
3.4.1. Fear of movement
The panel reached consensus on the suitability of the Fear Avoidance Beliefs Questionnaire (FABQ), the Tampa Scale for Kinesiophobia (TSK), and the eleven-item version of the TSK (TSK-11). Because most experts were unfamiliar with the NeckPix questionnaire, no consensus could be reached on the suitability of this questionnaire. However, both experts who rated the NeckPix questionnaire considered it suitable. The Chronic Pain Acceptance Questionnaire (CPAQ) was deemed unsuitable by 83.3% of the experts who scored the questionnaire. However, the number of experts who rated this questionnaire was too low (ie, <50%), and therefore, no recommendation could be made for this questionnaire (Table 3).
The panel reached consensus on the suitability of the Coping Strategies Questionnaire (CSQ), the revised version of the CSQ (CSQ-R), and the Chronic Pain Coping Inventory (CPCI). Although the experts who scored the Brief Pain Coping Inventory predominately found the questionnaire to be suitable, the number of experts who scored the list was too low to consider the questionnaire for recommendation. No consensus was reached on the suitability of the Pain Self-Efficacy Questionnaire (PSEQ) for measuring coping (Table 3).
The panel reached consensus on the suitability of the PSEQ and the 2-item version of the PSEQ (PSEQ-2). Because the number of experts who rated the Chronic Pain self-efficacy Scale (CPSS) was too low, a recommendation could not be made for this questionnaire. However, all experts who scored the CPSS agreed that it was suitable for measuring self-efficacy (Table 3).
The panel reached consensus on the Pain Catastrophizing Scale (PCS) and the CSQ-R (Table 3).
3.5. Sensitivity analyses
Seven experts who participated in round 3 did not participate in round 2. Therefore, we conducted sensitivity analyses of the quantitative results of round 3, in which the responses of these 7 experts were not taken into account. The sensitivity analyses showed that the ranking of the questionnaires, consensus level, and suitability did not differ meaningfully. For all factors, consensus was reached for the same questionnaires, and the consensus level was comparable with the full group results. For fear of movement, self-efficacy, and catastrophizing, the ranking of the questionnaires did not differ. For coping, the CSQ, CSQ-R, and CPCI were ranked in the top 3 in both the complete groups and the sensitivity analyses, but the order differed. In the complete group analysis, the CPCI achieved the highest level of consensus, and in the sensitivity analysis, the CSQ-R was ranked highest. Consensus levels were comparable in both groups for all 3 questionnaires. For a more elaborate overview of the sensitivity analysis results, see Appendix B (available online at http://links.lww.com/PAIN/A689).
In addition, we performed sensitivity analyses to determine whether the recommendations would differ if the experts who participated in development and/or validation of a questionnaire were excluded from the analyses. The results of the sensitivity analysis did not show substantial differences. The same questionnaires reached consensus, in the same order, with comparable agreement percentages. An overview of the sensitivity analysis results is shown in Appendix C (available online at http://links.lww.com/PAIN/A689).
3.6. Qualitative data analyses
3.6.1. Fear of movement
Some experts expressed concerns about the factor structure and validity of the FABQ and the TSK. For example: “Some questions (of the FABQ) do not appear to fit the structure well” and “(The FABQ) does not account for the entire range of fear about pain.” “(The TSK) is not focused enough on the influence of thoughts and actual avoidance patterns. Patients with a lot of fearful thoughts might not avoid (movement) and vice versa.” The experts found the FABQ, TSK, and TSK-11 instruments feasible for patients, clinicians, and researchers, although the questions of the TSK and TSK-11 that were scored reversely were described as somewhat unclear. The CPAQ was generally described as a feasible instrument. However, some experts questioned its validity (eg, “[The CPAQ] is not a measure of pain-related fear”). Most experts were unfamiliar with the NeckPix questionnaire. The 2 experts who were familiar with the questionnaire found it to be a “good questionnaire for chronic neck pain patients” and reported no negative experiences with it.
The experts considered the CSQ, CSQ-R, and CPCI to be useful for measuring coping because of the clinimetric properties and usability. Several experts preferred the CSQ-R over the CSQ because of its feasibility. One expert found the CSQ and CSQ-R to be outdated (eg, “Not up to date with current theories”). The PSEQ was described as “a good measure of pain self-efficacy, not coping.” And although general experiences with the Brief Pain Coping Inventory were positive, it was not the preferred instrument to measure coping (eg, “I believe there are better measures of the behaviour patterns included here, particularly for research”).
For self-efficacy, 3 experts questioned the relevance and the validity of the construct. They argued that self-efficacy is “not a precise and progressive concept,” and that the construct has not been thoroughly demonstrated to be “distinct from the construct of fear of pain.” Some experts concluded that “we need to move beyond this kind of variable” because “self-efficacy research is a dead end.” Both versions of the PSEQ were favoured over the CPSS for measuring self-efficacy, mainly because of the sound clinimetric properties and theoretical foundation. One expert, however, described the PSEQ to be “too close in item content to measuring disability.” The PSEQ-2 was deemed too limited by one expert. Both versions were deemed feasible, especially the 2-item version. For the CPSS, no negative experiences were reported.
The PCS was preferred over the CSQ-R, mainly because the PCS was believed to be more specific to measure catastrophizing than the CSQ-R. The PCS was considered feasible, valid, and responsive to change. Moreover, the PCS was described as “useful in a broad range of chronic pain conditions and (…) in healthy participants.” Contrary, the PCS was considered to be “quite long” and “suggestive.” Several experts questioned the validity of the CSQ-R to measure catastrophizing (eg, “Unclear validity as a standalone instrument for catastrophizing,” “The CSQ simply has too much irrelevant content” and “[The CSQ-R] does not measure catastrophizing”).
A more elaborate overview of the positive and negative experiences of the experts with each questionnaire is provided in Appendix D (available online at http://links.lww.com/PAIN/A689).
In the initial round of this modified Delphi study, the experts identified 30 self-administered questionnaires to assess fear of movement, coping, self-efficacy, and catastrophizing in people with musculoskeletal pain. After consecutive rounds, the experts reached consensus and recommended either 2 or 3 questionnaires for each psychosocial factor. The expert panel recommended the FABQ, TSK, and TSK-11 for fear of movement, the CSQ, CSQ-R and CPCI for coping, the PSEQ and PSEQ-2 for self-efficacy, and the PCS and CSQ-R for catastrophizing. These recommendations provide better guidance for various health care professionals and researchers across different domains (medicine, allied health, and mental health), who want to assess these factors. The recommendations have the potential to make the assessment of 4 psychosocial factors in patients with musculoskeletal pain more uniform, enabling comparison and pooling of data.
Although consensus was reached, some experts expressed concerns about specific constructs and questionnaires. It is noteworthy that several experts doubted the relevance and validity of measuring self-efficacy as a separate construct because it is not a precise concept and it is closely related to the construct of fear of pain. However, general consensus was that both versions of the PSEQ can be recommended to measure the construct. The factor structure of the FABQ and TSK for measuring fear of movement was questioned, as was the validity of the CSQ-R to measure catastrophizing. Nevertheless, general consensus was that these questionnaires are relevant and suitable for use in musculoskeletal pain.
The expert panel in our study was sufficiently large, with broad research and clinical expertise, reflecting the clinicians and researchers using these questionnaires in patients with musculoskeletal pain. Most experts had participated in development, translation, and/or validation of a questionnaire in a psychosocial domain relevant to the study. The response rates for all rounds were in line with previous Delphi studies, with approximately two-third of experts responding.1 Sensitivity analyses indicated that the results based on all experts did not differ meaningfully from the results based only on the experts who completed all rounds.
The consensus method, which is inherent to a Delphi study, favours well-known instruments over recently developed (eg, PROMIS CAT) and less-known questionnaires (eg, NeckPix). If a questionnaire was relatively new and most experts were not familiar enough with the questionnaire to form a valid opinion, it meant that it was (perhaps unjustifiably) not possible to a make recommendation. For example, recent developments in the area of computer adaptive testing were not considered in this study.2 These recommendations should therefore be seen in light of current scientific knowledge and practice, which is constantly evolving.
4.1. Future recommendations
Several questionnaires that were recommended are not yet validated in patients with (persistent) musculoskeletal pain. Future research should therefore focus on the validation of these questionnaires in patients with musculoskeletal pain. In addition, most of these questionnaires are not yet available in other languages than English. Therefore, to improve the use of these questionnaires, we encourage translation and subsequent validation of these questionnaires in multiple languages and settings. Because clear recommendations were formulated in this study, the recommended questionnaires should be prioritised when core outcome sets for musculoskeletal pain are developed.
In this study, the expert panel recommended the FABQ, TSK, and TSK-11 to assess fear of movement, the CSQ, CSQ-R, and CPCI for coping, the PSEQ and PSEQ-2 for self-efficacy, and the PCS and CSQ-R for catastrophizing.
Conflict of interest statement
The authors have no conflict of interest to declare.
The authors would like to thank all members of the expert panel for their input. The following experts provided consent to be listed: J. Beneciuk, A. Cano, G. Crombez, E. Denison, R. Esteve, S. Ferrari, M. Ferreira-Valente, R. Fillingim, J. Garcia-Campayo, M. Geisser, B. Gerdle, L. Goubert, C. Gustavsson, M. Hasenbring, J. de Jong, L. von Koch, A. Lopez-Martinez, A. Lynch-Jordan, A. Mannion, L. McCracken, M. Meeus, J. Miro, M. Peters, D. Ring, M. Robinson, M. Sandborgh, L. Simons, R. Smeets, B. Staal, D. Turk, C. Vanti, J. Vlaeyen, and K. Vowles.
This project was funded by a grant from the Scientific College Physical Therapy (WCF) of the Royal Dutch Society for Physical Therapy (KNGF).
Supplemental digital content
Supplemental digital content associated with this article can be found online at http://links.lww.com/PAIN/A689.
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Low back pain; Neck pain; Psychosocial factors; Instrument; Measurement; Delphi
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