Willing and Able: A Closer Look at Pain Willingness and Activity Engagement on the Chronic Pain Acceptance Questionnaire (CPAQ-8)


      An 8-item version of the Chronic Pain Acceptance Questionnaire (CPAQ-8) has recently been proposed and validated. The aims of this study were to further investigate the reliability and validity of the CPAQ-8 in a new sample. Questionnaires were completed by 550 people with chronic pain (478 online survey, 72 paper survey). A demographic and pain history questionnaire was administered along with the CPAQ-8 and measures of pain self-efficacy, pain catastrophizing, psychological flexibility in pain, anxiety, and mood. In addition, 105 respondents completed the CPAQ-8 within 6 weeks to provide test-retest reliability data. The 2-factor structure of the CPAQ-8 (Activity Engagement [AE] and Pain Willingness [PW]) was confirmed and had reasonable-to-good scale score reliability and test-retest reliability. Pain acceptance as measured by the CPAQ-8 was associated with less depression, anxiety, pain interference, fear of reinjury, pain catastrophizing, and psychological inflexibility in pain, and higher levels of satisfaction with life, pain self-efficacy, and general acceptance. Furthermore, pain acceptance fully mediated the relationship between reported pain severity and emotional distress (anxiety and depression) and partially mediated the relationship between pain severity and pain interference in a structural equation model. The test-retest reliability after 4 to 6 weeks ranged from .68 for PW to .86 for AE; the overall score correlation was .81. We conclude that the CPAQ-8 is a reliable and valid measure of pain acceptance and that the 2 subscales of the measure each make an individual contribution to the prediction of adjustment in people with chronic pain.


      The present study provides further evidence for the reliability and validity of the CPAQ-8. Support was found for the 2 related subscales, PW and AE, which appear to work in synergy to influence levels of pain interference and emotional distress in people living with chronic pain.

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        • Andersson G.
        • Kaldo-Sandström V.
        • Ström L.
        • Strömgren T.
        Internet administration of the Hospital Anxiety and Depression Scale in a sample of tinnitus patients.
        J Psychosom Res. 2003; 55: 259-262
        • Bendayan R.
        • Esteve R.
        • Blanca
        New empirical evidence of the validity of the Chronic Pain Acceptance Questionnaire: The differential influence of activity engagement and pain willingness on adjustment to chronic pain.
        Brit J Health Psych. 2011; 17: 314-326
        • Benson J.
        Developing a strong program of construct validation: A test anxiety example.
        Educ Meas. 1998; 17: 10-17
        • Breivik H.
        • Collett B.
        • Ventafrida V.
        • Cohen R.
        • Gallagher D.
        Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment.
        Eur J Pain. 2006; 10: 287-333
        • Bond F.W.
        • Hayes S.C.
        • Baer R.A.
        • Carpenter K.C.
        • Guenole N.
        • Orcutt H.K.
        • Waltz T.
        • Zettle R.D.
        Preliminary psychometric properties of the Acceptance and Action Questionnaire – II: A revised measure of psychological flexibility and acceptance.
        Behav Ther. 2011; 42: 676-688
        • Brown T.A.
        Confirmatory factor analysis of the Penn State Worry Questionnaire: Multiple factors or method effects.
        Behav Res Ther. 2003; 41: 1411-1426
        • Bryant F.B.
        • Cvengros J.A.
        Distinguishing hope and optimism: Two sides of a coin, or two separate coins?.
        J Soc Clin Psychol. 2004; 23: 273-302
        • Byrne B.M.
        Structural Equation Modelling With AMOS: Basic Concepts, Applications and Programming.
        Lawrence Erlbaum Associates, Inc., Mahwah, NJ2001
        • Carmines E.G.
        • Zeller R.A.
        Reliability and Validity Assessment.
        Sage, Thousand Oaks, CA1979
      1. Clark ME, Kori SH, Brockel J: Kinesiophobia and chronic pain: Psychometric characteristics and factor analysis of the Tampa Scale. APS Abstracts 15:77, 1996

        • Cleeland C.S.
        • Ryan K.M.
        Pain assessment: Global use of the Brief Pain Inventory.
        Ann Acad Med Singapore. 1994; 23: 129-138
        • Cook A.J.
        • Brawer P.A.
        • Vowles K.E.
        The fear-avoidance model of chronic pain: Validation and age analysis using structural equation modelling.
        Pain. 2006; 121: 195-206
        • Dahl J.
        • Wilson K.W.
        • Nilsson A.
        Acceptance and Commitment Therapy and the treatment of persons at risk for long term disability resulting from stress and pain symptoms: A preliminary randomized trial.
        Behav Ther. 2004; 35: 785-801
        • Elander J.
        • Robinson G.
        • Mitchell K.
        • Morris J.
        An assessment of the relative contribution of pain coping, negative thoughts about pain, and pain acceptance on health-related quality of life among people with haemophilia.
        Pain. 2009; 145: 169-175
        • El-Masri M.M.
        • Fox-Wasylyshyn S.M.
        Missing data: An introductory conceptual overview for the novice researcher.
        Can J Nurs Res. 2005; 37: 156-171
        • Field A.
        Discovering Statistics Using SPSS.
        Sage Publications Ltd., London, UK2005
      2., LLC (software). Palo Alto, CA.

        • Fish R.A.
        • McGuire B.
        • Hogan M.
        • Morrison T.G.
        • Stewart I.
        Validation of the Chronic Pain Acceptance Questionnaire (CPAQ) in an Internet sample and development and preliminary validation of the CPAQ-8.
        Pain. 2010; 149: 435-443
        • French D.J.
        • France C.R.
        • Vigneau F.
        • French J.A.
        • Evans R.T.
        Fear of movement/(re)injury in chronic pain: A psychometric assessment of the original English version of the Tampa Scale for Kinesiophobia (TSK).
        Pain. 2007; 127: 42-51
        • Gatchel R.J.
        • Peng Y.B.
        • Peters M.L.
        • Fuchs P.N.
        • Turk D.
        The biopsychosocial approach to chronic pain: Scientific advances and future directions.
        Psychol Bull. 2007; 133: 581-624
        • Grewal R.
        • Cote J.A.
        • Baumgartner H.
        Multicollinearity and measurement error in structural equation models: Implication for theory testing.
        Marketing Sci. 2004; 23: 519-529
        • Hayes S.C.
        • Duckworth M.P.
        Acceptance and commitment therapy and traditional cognitive behavior therapy approaches to pain.
        Cogn Behav Pract. 2006; 13: 185-187
        • Hayes S.C.
        • Luoma J.B.
        • Bond F.W.
        • Masuda A.
        • Lillis J.
        Acceptance and Commitment Therapy: Model processes and outcomes.
        Behav Res Ther. 2006; 44: 1-25
        • Keefe F.J.
        • Rumble M.E.
        • Scipio C.D.
        • Giordano L.A.
        • Perri L.M.
        Psychological aspects of persistent pain: Current state of the science.
        J Pain. 2004; 5: 195-211
        • Kline R.
        Principles and Practice of Structural Equation Modeling.
        The Guilford Press, New York, NY2005
        • Kori S.H.
        • Miller R.P.
        • Todd D.D.
        Kinesiophobia: A new view of chronic pain behaviour.
        Pain Manage. 1990; 3: 35-43
        • Kranz D.
        • Bollinger A.
        • Nilges P.
        Chronic pain acceptance and affective well-being: A coping perspective.
        Eur J Pain. 2010; 14: 1021-1025
        • Lamé I.E.
        • Peters M.L.
        • Kessels A.G.
        • Van Kleef M.
        • Patijn J.
        Test retest stability of the Pain Catastrophizing Scale and the Tampa Scale for Kinesiophobia in chronic pain over a longer period of time.
        J Health Psychol. 2008; 13: 820-826
        • Lappalainen R.
        • Lehtonen T.
        • Skarp E.
        • Taubert E.
        • Ojanen M.
        • Hayes S.C.
        The impact of CBT and ACT models using psychology trainee therapists: A preliminary controlled effectiveness trial.
        Behav Mod. 2007; 31: 488-511
        • McCracken L.M.
        Commentary: Toward understanding acceptance and psychological flexibility in chronic pain.
        Pain. 2010; 149: 420-421
        • McCracken L.M.
        • MacKichan F.
        • Eccleston C.
        Contextual cognitive-behavioral therapy for severely disabled chronic pain sufferers: Effectiveness and clinically significant change.
        Eur J Pain. 2007; 11: 314-322
        • McCracken L.M.
        • Vowles K.E.
        • Eccleston C.
        Acceptance of chronic pain: Component analysis and a revised assessment method.
        Pain. 2004; 107: 159-166
        • McCracken L.M.
        • Zhao-O’Brien J.
        General psychological acceptance of chronic pain: There is more to accept than pain itself.
        Eur J Pain. 2010; 14: 170-175
        • Meyer T.J.
        • Miller M.L.
        • Metzger R.L.
        • Borkovec T.D.
        Development and validation of the Penn State worry questionnaire.
        Behav Res Ther. 1990; 28: 487-495
      3. Nicholas MK. Self-efficacy and chronic pain. Presented at the annual conference of the British Psychological Society. St. Andrews, UK, 1989

        • Nicholas M.K.
        The pain self-efficacy questionnaire: Taking pain into account.
        Eur J Pain. 2007; 11: 153-163
        • Nicholas M.K.
        • Asghari A.
        Investigating acceptance in adjustment to chronic pain: Is acceptance broader than we thought?.
        Pain. 2006; 124: 269-279
        • Ning M.C.
        • Ming T.W.
        • Mae J.Y.
        • Ping C.P.
        Validation of the Chronic Pain Acceptance Questionnaire (CPAQ) in Cantonese-speaking Chinese patients.
        J Pain. 2008; 9: 823-832
        • Osman A.
        • Barrios F.X.
        • Kopper B.A.
        • Hauptman W.
        • Jones J.
        • O’Neill E.
        Factor structure, reliability, and validity of the Pain Catastrophizing Scale.
        J Behav Med. 1997; 20: 589-605
        • Osman A.
        • Barrios F.X.
        • Gutierrez P.M.
        • Kopper B.A.
        • Merrifield T.
        • Grittmann L.
        The Pain Catastrophizing Scale: Further psychometric evaluation with adult samples.
        J Behav Med. 2002; 23: 351-365
        • Pallant J.F.
        • Bailey C.M.
        Assessment of the structure of the Hospital Anxiety and Depression Scale in musculoskeletal patients.
        Health Qual Life Out. 2005; 3: 82
        • Powers M.B.
        • Zum Vörde Sive Vörding M.B.
        • Emmelkamp P.M.G.
        Acceptance and Commitment Therapy: A meta-analytic review.
        Psychother Psychosom. 2009; 78: 73-80
        • Raftery M.
        • Murphy A.W.
        • Normand C.
        • De la Harpe D.
        • Sarma K.
        • McGuire B.E.
        Chronic pain in the Republic of Ireland – community prevalence, psychosocial profile and predictors of pain-related disability: Results from the PRIME study, Part 1.
        Pain. 2011; 152: 1096-1103
        • Raftery M.
        • Ryan P.
        • Normand C.
        • Murphy A.W.
        • De la Harpe D.
        • McGuire B.E.
        The economic cost of chronic non-cancer pain in Ireland: Results from the PRIME study, Part 2.
        J Pain. 2012; 13: 139-145
        • Rodero B.
        • García-Campayo J.
        • Casanueva B.
        • del Hoyo Y.L.
        • Serrano-Blanco A.
        • Luciano J.V.
        Validation of the Spanish version of the Chronic Pain Acceptance Questionnaire (CPAQ) for the assessment of acceptance in fibromyalgia.
        Health Qual Life Outcomes. 2010; 12: 37
        • Schreisheim C.A.
        • Eisenbach R.J.
        An exploratory and confirmatory factor-analytic investigation of item wording effects on the obtained factor structures of survey questionnaire measures.
        J Manage. 1995; 21: 117-1193
        • Sullivan M.J.L.
        • Bishop S.C.
        • Pivik J.
        The Pain Catastrophizing Scale: Development and validation.
        Psychol Assess. 1995; 7: 524-532
        • Tan G.
        • Jensen P.
        • Thornby J.I.
        • Shanti B.F.
        Validation of the Brief Pain Inventory for chronic non-malignant pain.
        J Pain. 2004; 5: 133-137
      4. The Society of Clinical Psychology: American Psychological Association, Division 12: Acceptance and Commitment Therapy for Chronic Pain. Available at Accessed 13 October, 2012

        • Thorsell J.M.S.
        • Finnes A.
        • Dahl J.
        • Lundgren T.
        • Gybrant M.
        • Gordh T.
        • Buhrman M.
        A comparative study of 2 manual-based self-help interventions, acceptance and commttment therapy and applied relaxations for persons with chronic pain.
        Clin J Pain. 2011; 27: 716-723
        • Van Uden-Kraan C.F.
        • Drossaet C.H.C.
        • Taal E.
        • Shaw B.R.
        • Seydal E.R.
        • Van de Laar M.F.J.
        Empowering processes and outcomes of participation in online support groups for patients with breast cancer, arthritis or fibromyalgia.
        Qual Health Res. 2008; 18: 405-417
        • Vowles K.E.
        • McCracken L.M.
        • McLeod C.
        • Eccleston C.
        The Chronic Pain Acceptance Questionnaire: Confirmatory analysis and identification of patient subgroups.
        Pain. 2008; 140: 284-291
        • Wallace D.P.
        • Harbeck-Weber C.
        • Whiteside S.P.H.
        • Harrison T.E.
        Adolescent acceptance of pain: Confirmatory factor analysis and further validation of the chronic pain acceptance questionnaire, adolescent version.
        J Pain. 2011; 12: 591-599
        • Wetherell J.L.
        • Afari N.
        • Rutledge T.
        • Sorrell J.T.
        • Stoddard J.A.
        • Petkus A.J.
        • Solomon B.C.
        • Lehman D.H.
        • Liu L.
        • Lang A.J.
        • Hampton Atkinson J.
        A randomized, controlled trial of acceptance and commitment therapy and cognitive-behavioral therapy for chronic pain.
        Pain. 2011; 152: 2098-2107
        • Wicksell R.K.
        • Lekander M.
        • Sorjonen K.
        • Olsson G.L.
        The Psychological Inflexibility in Pain Scale (PIPS) – Statistical properties and model fit of an instrument to assess change processes in pain related disability.
        Eur J Pain. 2010; 14: 771.e1-771.e14
        • Wicksell R.K.
        • Melin L.
        • Olsson G.L.
        Exposure and acceptance in the rehabilitation of adolescents with idiopathic chronic pain – A pilot study.
        Eur J Pain. 2007; 11: 267-274
        • Wicksell R.K.
        • Olsson G.L.
        • Hayes S.C.
        Psychological flexibility as a mediator of improvement in Acceptance and Commitment Therapy for patients with chronic pain following whiplash.
        Eur J Pain. 2010; 14: 1059.e1-1059.e11
        • Wicksell R.K.
        • Olsson G.L.
        • Hayes S.C.
        Mediators of change in Acceptance and Commitment Therapy for pediatric chronic pain.
        Pain. 2011; 152: 2792-2801
        • Wicksell R.K.
        • Olsson G.L.
        • Melin L.
        The Chronic Pain Acceptance Questionnaire (CPAQ) – further validation including a confirmatory factor analysis and a comparison with the Tampa Scale of Kinesiophobia.
        Eur J Pain. 2009; 13: 760-768
        • Wicksell R.K.
        • Renöfält J.
        • Olsson G.L.
        • Bond F.W.
        • Melin L.
        Avoidance and cognitive fusion – Central components in pain related disability? Development and preliminary validation of the Psychological Inflexibility in Pain Scale (PIPS).
        Eur J Pain. 2008; 12: 491-500
        • Woolrich R.A.
        • Kennedy P.
        • Tasiemski T.
        A preliminary psychometric evaluation of the Hospital Anxiety and Depression Scale (HADS) in 963 people living with a spinal cord injury.
        Psychol Health Med. 2006; 11: 80-90
        • Wong N.
        • Rindfleisch A.
        • Burroughs J.E.
        Do reverse-worded items confound measures in cross-cultural consumer research? The case of the material values scale.
        J Consum Res. 2003; 30: 72-91
        • Zigmond A.S.
        • Snaith R.P.
        The Hospital Anxiety and Depression Scale.
        Acta Psychiatr Scand. 1983; 67: 361-370