The coping strategy questionnaire.Description
General description: The coping strategy questionnaire (CSQ), (Rosenstiel & Keefe 1983) in its original version consists of 50 items assessing patient self rated use of cognitive and behavioural strategies to cope with pain. It comprises six subscales for cognitive strategies (ignoring pain, reinterpretation of pain, diverting attention, coping self statements, catastrophising, praying/hoping) and two subscales for behavioural strategies (increasing activity levels and increasing pain behaviours). Each coping strategy subscale consists of six items measured with a numerical rating scale ranging from 0 (never do that) to 6 (always do that) indicating how frequently the strategy is used to cope with pain. Each subscale has a maximum score of 36 and a minimum score of 0. An additional two single item questions each with a scoring range of 0-6 are used as effectiveness ratings of control over pain and ability to decrease pain. The CSQ takes approximately 5 minutes to complete.
Reliability and validity: In a sample of 61 patients with chronic low back pain (CLBP), Rosenstiel and Keefe (1983) reported the internal consistency for the subscales with Cronbach's alphas ranging from 0.71 to 0.85, except for the increasing pain behaviour subscale which had an internal consistency of 0.28. However, in a sample of 282 CLBP patients, Jensen and Linton (1993) showed that all 8 subscales of the CSQ Swedish version have an internal consistency ranging from 0.69 to 0.84. Similarly, in patients with lung cancer, the CSQ subscales have shown good internal consistency with Cronbach's alphas ranging from 0.60 to 0.90 (Wilkie & Keefe 1991). Test-retest reliability for a 1 day interval has been reported to range between 0.68 and 0.91 (Main & Waddell 1991), 0.48-0.71 for a 1 week interval and 0.58-0.84 for a 5 week interval (Jensen & Linton 1993).
Support exists for the construct validity of the CSQ in chronic pain populations where significant correlations have been shown with questionnaires measuring depression, anxiety, self-efficacy and physical functioning (Lawson et al 1990, Geisser et al 1994, Swartzman et al 1994, Burckhardt et al 1997).
Studies using factor analysis to investigate the underlying dimensions of the 8 CSQ subscales and 2 effectiveness items have frequently reported a three factor solution consisting of 1) cognitive coping and suppression, 2) behavioural activity, and 3) pain control/rational thinking (Rosenstiel & Keefe 1983, Keefe & Dolan 1986, Lawson 1990, Geisser et al 1994, Burckhardt et al 1997). Using exploratory factor analysis on an individual item level, two studies obtained a five factor solution (Tuttle et al 1991, Swartzman et al 1994). Recognising the small samples used in previous studies, item level exploratory factor analysis was performed on the CSQ from a large sample of 965 patients CLBP revealing a six factor solution similar to the subscales originally derived in the CSQ (Robinson et al 1997).
Riley and Robinson (1997) compared the five and six factor solutions for the CSQ using linear structural equation modelling. From the results, Riley and Robinson (1997) recommended a revision of the coping strategy questionnaire (CSQ-R) retaining 27 items from the original CSQ. This included all six items of the catastrophising subscale, five items from each of the ignoring pain and reinterpreting pain sensations subscales, four items from coping self-statements and diverting attention subscales, and three items related to praying factors. In a recent study on patients with cancer related pain, Utne et al (2009) also showed less factorial variance in the CSQ-R than the original CSQ and recommends the CSQ-R for use in clinical research.
Monitoring coping strategies is of clinical importance as they have been shown to mediate the influence of pain intensity on functional disability and quality of life (Abbott et al 2010) and to influence the adjustment of pain (Rosenstiel & Keefe 1983). The CSQ has been shown to be valid for use in several different patient groups such as osteoarthritis, knee replacement surgery, rheumatoid arthritis, fibromyalgia, low back pain, lumbar spine surgery, and even cancer-related pain.
The CSQ is a useful clinical tool for the screening of coping styles. It provides information for patients and clinicians on the efficacy of coping strategies and those strategies needing addressing to help facilitate pain control and mediate improvement of functional outcomes. Data on the CSQ-R sensitivity of change is lacking. More research using the CSQ-R is needed to improve the questionnaire's validity as an outcome measure and provide more extensive normative data.
Abbott AD (2010) Physiotherapy, in press.
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Karolinska Institute, Sweden