New Pain Scale Developed to Better Assess Impact of Chronic Pain

Researchers have developed a new self-reported pain scale utilizing more detailed descriptions of patient activity patterns

Researchers from the University of Malaga, Spain, have developed a new tool to help clinicians assess the impact of chronic pain on daily activities, according to a study published in the April issue of The Journal of Pain.1

Known as the Activity Patterns Scale (APS), the self-report measure breaks down 3 general activities (avoidance, persistence, and pacing) into 8 more specific patterns: pain avoidance, activity avoidance, task-contingent persistence, excessive persistence, pain-contingent persistence, pacing to increase activity, pacing to conserve energy, and pacing to reduce pain.

Patients with chronic pain often have to modify how they perform activities of daily living, which can impact their sense of wellbeing and quality of life.

Scale Construction and Validation

The APS was constructed and validated in 2 studies. The first of these evaluated the internal structure of the APS in 291 patients (262 women, 29 men; mean age, 52 y) with chronic pain from rheumatic diseases. Three different factor structures were tested using confirmatory factor analyses via structural equation modeling.

Confirmatory factor analysis supported the validity of a 24-item APS with 8 subscales for related factors. The new version was found to be slightly superior to the 6-factor structure, indicating that avoidance, persistence, and pacing should be thought of as multidimensional constructs.

Researchers also examined correlations between each APS subscale, and also between their matched subscales on the ‘‘Patterns of Activity Measure-Pain (POAM-P).” The highest correlation was found between pain avoidance and pacing for pain reduction (r = .51), and the lowest between pacing for increasing activity level and both avoidance subscales (pain avoidance and task avoidance). As expected, high correlations were found when comparing APS subscales with their matched subscales on the POAM-P.

In the second study, researchers examined the association between the APS subscales and pain intensity, daily functioning, impairment, and positive and negative affect. The study included 111 patients with chronic pain (81 women, 30 men; mean age, 53 y) who completed the APS, a Positive and Negative Affect Schedule, a 10-point pain scale, and the Impairment and Functioning Inventory.

Results showed an association between activity avoidance and daily functioning and impairment. Negative affect was positively associated with activity avoidance and excessive persistence, and negatively associated with task-contingent persistence; the latter was also positively associated with positive affect.

“[A]lthough further research is needed, this study provides evidence that the APS, which assesses 8 activity patterns with a relatively low number of items, is a promising instrument for clinical practice and research,” the authors write.

Clinical Pain Advisor had the opportunity to discuss the APS in greater detail via e-mail with lead author Rosa Esteve, PhD.

Clinical Pain Advisor: What led you and your colleagues to develop the APS and how did it evolve?

Dr Esteve: As part of our current research project, we needed to measure activity patterns. When reviewing the literature, we found that several authors suggested there may be a need to develop new measures of activity patterns or to refine existing ones. In particular, 3 papers stood out and were very influential in our conceptualization of the instrument: an article by Kindermans et al., and two by Nielson et al.2-4

The Kindermans et al. article used exploratory factor analyses of various activity patterns self-report measures and identified 6 patterns: pain avoidance, activity avoidance, task-contingent persistence, excessive persistence, pain-contingent persistence, and pacing.2

The articles by Nielson et al. suggested that existing measures did not include some key pacing subdomains and that future measures should be developed that address specific pacing behaviors based on the goal of the pacing.3,4

Based on the aforementioned research, the 3 items with the highest factor loading in each activity patterns dimension found by Kindermans et al. were included in our instrument, along with 3 goal-based pacing scales.

Clinical Pain Advisor: In validating the APS, what was your key finding?

Dr Esteve: Our key finding is that the goals of avoidance, persistence, and pacing behaviors are crucial factors that influence disability and wellbeing, rather than being considered intrinsically adaptive or maladaptive. This distinction between functional and dysfunctional forms of avoidance, persistence, and pacing could contribute to refining the treatment instructions aimed at regulating patients’ activity and in providing a more individualized approach to care.

Clinical Pain Advisor: Any area for future development or refinement of the scale?

Dr Esteve: Currently, professors Madelon Peters, a co-developer of the APS, and Hanne Kindermans, whose article helped lay the foundation of the scale, are working on translating/adapting the instrument into Dutch. At the same time, they are investigating the validity of the dimensions of the APS activity patterns by studying if their relationship with measures of psychosocial functioning differs from that of existing activity patterns measures. In addition to this research, future research should test the construct validity of the dimensions included in the instrument using objective measures, rather than just relying on self-reports.

Clinical Pain Advisor: How do you see the scale being used in clinical practice?

Dr Esteve: For clinicians, the instrument offers the possibility of a more detailed description of activity patterns and of making more specific predictions of the relationship of activity patterns with wellbeing using exploratory factor analyses of various activity patterns self-report measures. Having this information can enable clinicians to make treatment instructions more specific. Nevertheless, at this moment, the instrument should be used cautiously because it is still in the initial stages of development.

Clinical Pain Advisor: Can physicians obtain a copy of the scale for use? If so, where?

Dr Esteve: Physicians can request a copy of the APS via e-mail. Such requests can be sent to me at [email protected].


1. Esteve R, Ramírez-Maestre C, Peters ML, Serrano-Ibáñez ER, Ruíz-Párraga GT, López-Martínez AE. Development and initial validation of the Activity Patterns Scale in patients with chronic pain. J Pain. 2016;17(4):451-461.

2. Kindermans HP, Roelofs J, Goossens ME, Huijnen IP, Verbunt JA, Vlaeyen JW. Activity patterns in chronic pain: underlying dimensions and associations with disability and ... . J Pain. 2011;12(10):1049-1058.

3. Nielson WR, Jensen MP, Karsdorp PA, Vlaeyen JW. Activity pacing in chronic pain: concepts, evidence, and future directions. Clin J Pain. 2013;29(5):461-468.

4. Nielson WR, Jensen MP, Karsdorp PA, Vlaeyen JW. A content analysis of activity pacing in chronic pain: what are we measuring and why? Clin J Pain. 2014;30(7):639-645.

This article originally appeared on Clinical Pain Advisor