Routinely collected clinical databases are used increasingly in research and can be broadly classified as administrative databases and clinical (disease-based or treatment-based) databases.4 We have reported normative data for 4 questionnaires that are commonly used in pain management, obtained from a sample of approximately 13,000 patients from pain clinics in Australia and New Zealand. These data update and extend those reported by Nicholas et al.19 and use a much larger sample of patients from multiple clinics (vs just one), and include the questionnaires required as part of an Australian and New Zealand health services initiative (ePPOC). The low proportion of missing responses indicates the measures are broadly acceptable to pain patients, and that the calculated norms are based on valid and reliable data.
It is noteworthy that there was little difference in pain severity and interference scores between the different groupings, but some differences were found for the mood (DASS) and cognitive (PSEQ and PCS) questionnaires. Most notably, scores tended to worsen and then improve with older age, to worsen with a greater number of pain sites, and to be worse for people who were unemployed and/or injury compensation cases. Also worth noting are the worse scores for those whose pain was attributed to an accident or injury (many of whom were covered by compensation insurance) and the better outcomes reported by those reporting cancer-related pain. It should be noted, however, that the proportion reporting cancer-related pain was relatively small (n = 222, 1.1% of cases) and unlikely to be representative of those in the more acute and terminal stages of their illness, but nevertheless, they had been referred to a pain clinic that suggests pain was a recurring problem. It should also be emphasised that the relationships between the questionnaires and demographic characteristics are associations, and no causal inferences can be made.
Despite these caveats, the large size of this data set and the widespread source of the data indicate these data can be used to interpret an individual's score and the mean of a sample of individuals for each subscale of the 4 questionnaires reported, taking into account information about sex, age, or pain sites. The availability of these data will facilitate interpretation of scores on these instruments, in both research and clinical contexts (for discussion see Ref. 28). Nicholas et al.19 highlighted the utility of normative data using examples of clinical application of such data for individual patients. Such data can also be useful in gauging the characteristics of samples used in clinical research, especially when the same measures are employed. For example, Gardner et al.11 used the DASS and PSEQ (among other measures) to evaluate the use of goal setting by people with chronic low-back pain. According to the normative data presented here, the mean scores on these scales would have placed them in the normal (nondepressed mood) range on the DASS (5-10th percentile) and at very high pain self-efficacy (90th percentile) before treatment started. This is clearly a different sample to most of those attending pain clinics in Australia and New Zealand and needs to be borne in mind when drawing conclusions from that study.
On a broader level, the most recent Cochrane review of psychological therapies for chronic pain33 concluded that rather than more general trials of treatments, what was needed was studies that could “identify which components of CBT work for which type of patient on which outcome/s”. However, examination of the studies included in the review itself reveals considerable variation in the outcome measures used, most of which had no normative comparators, indicating a problem in addressing the questions posed by those researchers.
Another potential limitation is that the norms reported here are based on patient-rated assessment tools and questions and therefore only include data from those patients who are able to complete the measures. Individuals from non–English-speaking backgrounds or with low literacy levels will be underrepresented in these data. Finally, it is worth noting that about 3% of the sample had experienced pain for less than 3 months, which fails to satisfy the common criterion of chronic pain as having persisted for at least 3 months.27 Given the small percentage of such patients, this is not of great concern.
In summary, large standardised databases such as the ePPOC database have many uses, including the facilitation of interpretation of both group- and individual-level pain data by providing normative data for comparison across groups and centres, and between pain clinic treatment populations and those participating in clinical trials. One recent example that is topical is whether those people participating in online pain self-management programs are different (on these measures) to those attending pain clinics. Friesen et al.,10 for example, reported data from their online pain course with 60 diagnosed fibromyalgia patients (95% being female, with a mean age of 48 years). Looking at mean pretreatment scores for the treatment group, the BPI (pain) score was 5.4, vs 6.4 for the norms for people in the 40- to 50-year age group, and on the BPI (interference scale), the scores were 6.6 vs 7.3, respectively. On the PSEQ, it was 22.9 vs 18.9, respectively. These differences would suggest the online participants had slightly less severe pain and pain interference than the pain clinic samples. The online sample also reported slightly higher pain self-efficacy, which may make them more likely to accept a self-management approach. For example, Coughlan et al.6 found that chronic pain patients with mean initial PSEQ scores of 16.6 (SD:11.4) were significantly more likely to drop out an inpatient pain management program than those who completed the program (who had mean initial PSEQ scores of 24.4, SD: 11).
The authors have no conflict of interest to declare.
Ms Jenni Johnson, Manager, ACI Pain Network, NSW Health, Sydney, Australia.
Supplemental digital content
Supplemental digital content associated with this article can be found online at http://links.lww.com/PAIN/A743.
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