dutchtranslationandadaptationofthetreatmentbeliefs...

Research ArticleDutch Translation and Adaptation of the Treatment BeliefsQuestionnaire for Chronic Pain Rehabilitation

Harriet Wittink 1 Janke Oosterhaven1 Jos Dekker2 Cas Kruitwagen3 Walter Deville34

Else Ellens5 and Carin Schroder6

1Research Group Lifestyle and Health Utrecht University of Applied Sciences Utrecht Netherlands2Heliomare Rehabilitation Center Wijk aan Zee Netherlands3Julius Centre for Health Sciences and Primary Care University Medical Center Utrecht Utrecht Netherlands4Amsterdam Institute of Social Science Research University of Amsterdam Amsterdam Netherlands5De Hoogstraat Rehabilitation Utrecht Netherlands6Ecare4you Amersfoort Netherlands

Correspondence should be addressed to Harriet Wittink harrietwittinkhunl

Received 21 December 2018 Revised 10 April 2019 Accepted 19 May 2019 Published 27 June 2019

Academic Editor Anna Maria Aloisi

Copyright copy 2019 Harriet Wittink et al )is is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work isproperly cited

Background )e Treatment Beliefs Questionnaire has been developed to measure patientsrsquo beliefs of necessity of and concernsabout rehabilitation Preliminary evidence suggests that these beliefs may be associated with attendance of rehabilitation)e aimof this study was to translate and adapt the Treatment Beliefs Questionnaire for interdisciplinary pain rehabilitation and toexamine the measurement properties of the Dutch translation including the predictive validity for dropout Methods )equestionnaire was translated in 4 steps forward translation from English into Dutch achieving consensus back translation intoEnglish and pretesting on providers and patients In order to establish structural validity internal consistency construct validityand predictive validity of the questionnaire 188 participants referred to a rehabilitation centre for outpatient interdisciplinarypain rehabilitation completed the questionnaire at the baseline Dropout was measured as the number of patients starting but notcompleting the programme For reproducibility 51 participants were recruited at another rehabilitation centre to complete thequestionnaire at the baseline and one week later Results We confirmed the structural validity of the Treatment beliefsQuestionnaire in the Dutch translation with three subscales necessity concerns and perceived barriers internal consistency wasacceptable with ordinal alphas ranging from 066ndash087 Reproducibility was acceptable with ICC21 agreement ranging from067ndash081 Hypotheses testing confirmed construct validity similar to the original questionnaire Predictive validity showed thequestionnaire was unable to predict dropouts Conclusion Cross-cultural translation was successfully completed and the DutchTreatment Beliefs Questionnaire demonstrates similar psychometric properties as the original English version

1 Introduction

Interdisciplinary pain rehabilitation has been found to be ef-fective at reducing medication use reducing emotional distressreducing health care utilization reducing iatrogenic conse-quences and increasing physical activity and return to work [1]

Despite its efficacy pain rehabilitation nonadherence anddropout remain a major problem A recent systematic reviewon interdisciplinary treatment of chronic musculoskeletal

pain reports dropout ranging from 10 to 51 [2 3] within the8 included studies from the United States Denmark theNetherlands and United Kingdom [4] Dropout was definedas ldquopatients with chronic pain who were referred to a chronicpain management programme who initiated (participated inthe baseline assessments) but discontinued prior to com-pletion of the entire programmerdquo [5] No high quality researchwas available on predictors of dropout and most predictorswere only studied once

HindawiPain Research and ManagementVolume 2019 Article ID 9596421 10 pageshttpsdoiorg10115520199596421

According to the common sense model of self-regulation(CSM) [6ndash8] patients develop beliefs about their conditionor illness which influence the interpretation of informationand experiences and which guide behaviour [9] Patientstherefore bring preexisting beliefs about their illness andtreatment (illness representations and treatment represen-tations) to pain rehabilitation which influence their eval-uation of the treatment their adherence and even beneficialor adverse outcomes [10] Several meta-analyses howeverhave shown a very weak relationship between individualillness beliefs and adherence in patients with chronic dis-eases [11 12] Aujla et al [12] report that an aspect of theCSM that has not been captured by their review because of alack of availability of data from included papers concernstreatment beliefs Beliefs about medications is one of the fewtreatment representations that have been studied system-atically [8] Research conducted with patients with a varietyof long-term conditions suggests that the key beliefsinfluencing patientsrsquo common sense evaluations of pre-scribed medicines can be grouped under two categoriesperceptions of personal need for treatment (necessity beliefs)and concerns about a range of potential adverse conse-quences [10 13 14] )is ldquoNecessity-Concerns Framework(NCF)rdquo potentially offers a convenient model for cliniciansto elicit and address key beliefs underpinning patientsrsquo at-titudes and decisions about treatment [10] A recent meta-analytic review of the NCF about medicines prescribed forlong-term conditions showed that higher adherence wasassociated with stronger perceptions of necessity of treat-ment and fewer concerns about treatment [10]

Compared to the body of evidence on treatment beliefsabout medication there is scant information on treatmentbeliefs about rehabilitation Beliefs about rehabilitation havebeen shown to make a significant contribution to the pre-diction of rehabilitation outcomes in one study [15] andthey are thought to strongly influence adherence to treat-ment [10 14] )e Treatment Beliefs Questionnaire wasinitially developed as basis for predicting cardiac re-habilitation attendance after acute myocardial infarction)is 13 item questionnaire had good structural validity withinternal consistencies gt07 for all domains resulting inacceptable construct validity [16] An adapted version wasused in elderly patients with COPD to test the associationbetween treatment beliefs and baseline test performance andresponse to treatment [17] For pain rehabilitation no suchquestionnaire exists even though treatment beliefs appear tobe important in predicting adherence to treatment ordropout of patients with chronic pain entering an in-terdisciplinary pain rehabilitation programme Severalstudies investigating adherence to cystic fibrosis chronicobstructive pulmonary disease (COPD) and cardiac re-habilitation programmes have found that patients whoexpressed concerns about the programme or who reportedpractical barriers to attendance were less likely to attend[16ndash19]

Our first aim was to translate and adapt a questionnairebased on the NCF initially developed and validated forcardiac rehabilitation research [16 20] later adapted andvalidated for use in an elderly COPD population [17] for

patients attending interdisciplinary pain rehabilitationprogrammes Our second aim was to describe the mea-surement properties of the translated and adapted treatmentbeliefs questionnaire including the predictive validity fordropout

2 Methods

21 Participant Recruitment Consecutive patients withchronic noncancer pain who were referred to one of tworehabilitation centres (Heliomare Wijk aan Zee and DeHoogstraat Revalidatie Utrecht the Netherlands) wereinvited to participate during the intake phase betweenOctober 2012 and October 2016 All participants providedinformed consent and gave researchers permission toobtain sociodemographic and medical information fromtheir medical records Both rehabilitation centres con-ducted comparable interdisciplinary pain managementprogrammes for patients with chronic pain consisting ofcognitive behavioural therapy with pain neuroeducationand exercise therapy Patients who were judged appropriatecandidates for the interdisciplinary programme by either aphysiatrist (Heliomare) or a physiatrist pain consultantand a psychologist (Hoogstraat) were entered into theprogramme to start an initial period of assessment (di-agnostic phase) by the other members of the team (psy-chologist physical therapist occupational therapist socialworker sport professional and music therapist) in order tocome to an appropriate treatment plan (treatment phase)Excluded from the study were participants who were un-able to read or write Dutch

)e study was registered with the Medical EthicsCommittee of the Academic Medical Centre of Amsterdamwhich declared that it did not fall under the scope of theldquoMedical Research Involving Human Subjects Actrdquo and bythe internal research ethics review boards of the two re-habilitation centres All patients provided written informedconsent and were treated in accordance to the declaration ofHelsinki [21]

22 Materials )e treatment beliefs questionnaire wasdeveloped by Cooper et al [16] for patients referred tocardiac rehabilitation based on the results from interviewstudies consistent with the NCF [20] )e questionnaireconsists of 13 items across 4 domains necessity (5 items)concerns (3 items) practical barriers (3 items) and per-ceived personal suitability (2 items) Internal consistency ofthe 4 domains varied between Cronbachrsquos α 070 forpractical barriers and α 079 for concerns Items are scoredon a 5-point Likert scale from 1 strongly disagree to 5strongly agree Higher scores on the necessity subscale in-dicate the patient is more likely to perceive treatment asnecessary and to be clear as to how it will benefit Higherscores on the concerns subscale indicate the patient hasconcerns about participating in treatment Higher scores onpractical barriers indicate there might be practical barriers toparticipating in treatment A higher score on perceivedpersonal suitability indicates a greater belief that (cardiac)

2 Pain Research and Management

rehabilitation is probably suitable for a younger more activeperson

In addition to the Treatment Beliefs Questionnaireparticipants in the Heliomare programme completed theDutch versions of the Brief Illness Perception Questionnaire(Brief IPQ) [22] and the Pain Self-Efficacy Questionnaire(PSEQ) [23] )e Brief IPQ has 8 dimensions (perceivedconsequences timeline acute-chronic amount of perceivedpersonal control treatment control identity (symptoms)concern about the illness coherence of the illness andemotional representation) and uses one single item on a0ndash10 scale to assess each dimension )e last item assessescausal perceptions by asking patients to list the three mostlikely causes for their illness )e PSEQ is a 10-item self-report questionnaire designed to assess the degree of con-fidence in performing a number of activities despite painEach item is rated on a 7-point Likert-type scale (0 not atall confident 6 completely confident) Total scores rangefrom 0 to 60 with a higher score indicating greater self-efficacy for functioning despite pain Both Dutch versions ofthe Brief IPQ and the PSEQ have good psychometricproperties [24 25]

23 Procedure For practical purposes 51 participants wererecruited between January and December 2014 in re-habilitation centre De Hoogstraat to complete the ques-tionnaire at the baseline and one week later to determinereproducibility of the questionnaire Participants completedthe questionnaire before and after the one week diagnosticphase Our assumption was that participants would remainstable during this period as treatment was not yet initiatedAt the second administration the participants and raterswere not aware of the scores on the first administration Testconditions were similar for all measurements

For all other measurement properties (item-level ana-lyses structural validity internal consistency constructvalidity and predictive validity) the participants completedthe questionnaires at the baseline at the Heliomare Re-habilitation Centre

24 Design and Analysis For reproducibility a test-retestwas performed for all other measurement properties weused a prospective longitudinal design

Data analysis was performed using SPSS version 23 (IBMCorp Released 2012 IBM SPSS Statistics for WindowsVersion 230 Armonk NY) R statistical package version311 [26] and Lisrel 88 (LISREL 880 for Windows [27])Questions 4 and 6 were reverse scored for all analyses If thenumber of missings per domain was lt2 missing item scoreswere replaced by the mean of the not missing items of thedomain

Means (SD) were calculated for the demographic dataDifferences in age and gender between the two locationswere tested by means of an independent t-test and chi-square analysis respectively Skewness tests were used to testfor normal distribution on item level and domain level Tointerpret skewness we used the rule of thumb by Bulmer[28] If skewness was less than minus1 or greater than +1 the

distribution was considered highly skewed If skewness wasbetween minus1 and minusfrac12 or between +frac12 and +1 the distributionwas moderately skewed If skewness was between minusfrac12 and+frac12 the distribution was approximately symmetric

In total responses were missing on 94 of the items ofthe Treatment Beliefs Questionnaire As all items had anabnormal distribution we used polychoric correlations foritem-level analyses Per item no more than about 1 wasmissing

241 Item-Level Analyses )e distribution of item re-sponses was determined by calculating the response optionfrequencies Interitem correlations were determined usingpolychoric correlations acknowledging that the 5-pointLikert scale is in fact ordinal )e polychoric correlationcoefficient is a measure of association for ordinal variableswhich rests upon an assumption of an underlying jointcontinuous distribution It allows for other distributionalassumptions than the joint normal distribution [29] Cor-relations in the approximate range of 030ndash070 are desirableas lower values would indicate lack of homogeneity and highcorrelations would indicate item redundancy [30]

25 Structural Validity Initially an exploratory factoranalysis (EFA) with promax rotation was applied to thecorrelation matrix of polychoric correlations to explore thedimensional structure of the Dutch pain Treatment BeliefsQuestionnaire Item loadings above 030 were used to retainitems under one factor Subsequently confirmatory factoranalyses (CFA) with a varimax rotation using the polychoriccorrelation matrix were performed to confirm the threedomains of the Treatment Beliefs Questionnaire We per-formed a confirmatory factor analysis using items 1ndash5 itemsfor necessity (factor 1) items 6ndash9 for concerns (factor 2) anditems 10 and 11 for practical barriers (factor 3) as reported inthe literature [17] and we conducted a confirmatory factoranalysis based on the results of our exploratory factoranalysis using items 1ndash6 for necessity items 7ndash9 for con-cerns and items 10 and 11 for practical barriers To de-termine howwell themodels fit to our data we calculated thefollowing (1) the root mean square error of approximation(RMSEA) the RMSEA ranges from 0 to 1 A value of 0indicates perfect fit Hu and Bentler [31 32] suggestedle 006as a cutoff value for a good fit (2) Comparative fit index(CFI) CFI values range from 0 to 1 with larger valuesindicating better fit A CFI value ge095 is accepted as anindicator of good fit [32] (3) Goodness of fit index (GFI) andadjusted goodness of fit index (AGFI) the GFI and AGFIrange between 0 and 1 with a value of gt09 generally in-dicating acceptable model fit [33]

26 Internal Consistency Internal consistency reliabilitymeasures the extent to which all items within a scale areindeed capturing the same construct Ordinal alpha wascalculated for the domains as established by the confirma-tory factor analysis [34] Alpha for a scale should not besmaller than 070 when used for research purposes at least

Pain Research and Management 3

080 for applied settings and greater than 090 or even 095for high-stake individual-based educational diagnostic orclinical purposes [35]

261 Reproducibility As the data for the itemswere skewed aquadratic weighted kappa was calculated as a measure of test-retest reliability for each item Landis and Koch [36] proposedthe following as standards for strength of agreement for thekappa coefficientle0 poor 001ndash020 slight 021ndash040 fair041ndash060moderate 061ndash080 substantial and 081ndash1 almost perfect For test-retest reliability of the three do-mains (necessity concerns and practical barriers) we used atwo-way random intraclass correlation (ICC21 agreement) as weconsidered sum scores of these domains to be at interval levelICC values above 07 were considered to be acceptable [38]To determine agreement standard error of measurement(SEM SD

(1minus ICC)

1113968) was calculated using Cohenrsquos formula

for pooled SD [37] )e smallest detectable change for in-dividuals was calculated (SDC 196 times

2

radictimes SEM) which

reflects the smallest within-person change in score that withplt 005 can be interpreted as a ldquorealrdquo change above mea-surement error in one individual (SDCind) [38]

27 Construct Validity Construct validity was tested byexamining the correlations between the three subscales ofthe Treatment Beliefs Questionnaire and the Brief IPQ andthe PSEQ Based on previous research [16] we hypothesizedthere would be (1) medium positive correlations between thenecessity domain and the IPQ item on treatment control (2)medium positive correlations between concerns and IPQconsequences IPQ concerns and IPQ emotional responseand a small negative correlation between Concerns and totalPSEQ score and (3) no or insignificant correlations betweenpractical barriers and any of the IPQ items or the PSEQ

We defined the strength of a correlation as anythingsmaller than 010 as insignificant r 010 to 029 smallr 030 to 049 medium and r 050 to 10 large [39] As thedistribution of the IPQ item scores was skewed and therelationship with the necessity domain nonlinear we usedSpearman correlations For the association between con-cerns and the PSEQ we used a Pearson correlation (rs)

28 Predictive Validity Finally we tested the ability of theTreatment Beliefs Questionnaire to distinguish betweendropouts and nondropouts Dropout was defined as ldquopa-tients with chronic pain who were referred to a chronic painmanagement programme who initiated (participated in thebaseline assessments) but discontinued prior to completionof the entire programmerdquo [5] For this purpose a receiveroperating curve (ROC) and its area under the curve (AUC)was calculated for all three subscales

3 Results

31 First Aim Translation and Adaptation of the TreatmentBelief Questionnaire )e Treatment Beliefs Questionnairewas translated in 4 stages by 2 translators (HW and CS) as

recommended by Beaton et al [40] Both translators werebilingual and had expertise in the treatment of chronic painOne translator a psychologist (CS) was an expert in thecommon sense model of self-regulation In stage 1 the twotranslators independently performed forward translationsfrom English into Dutch in stage 2 consensus by discussionwas reached among the translators In stage 3 the twotranslators independently translated the synthesized trans-lation back into the original English language In stage 4 wepretested the questionnaire on both health care providersand patients

Two psychologists and 2 psychology assistants with ex-pertise in treating patients with chronic pain 2 pain con-sultants and 2 experienced pain physical therapists wereasked their opinion regarding the range and relevance of thequestions )eir response to the range and relevance of itemswas positive with one additional item suggested ldquoin the daysbetween the rehabilitation sessions I am probably very tiredfrom exercisingrdquo as proposed by Fischer et al [17] whoadapted the questionnaire for patients with COPD For theperceived suitability questions there was consensus that thesequestions were irrelevant as among patients with chronicpain age is not perceived to be a barrier to rehabilitation Onequestion of the practical barriers was dropped (ldquoit would befinancially difficult to take time off work to attend re-habilitationrdquo) as it was felt this is not an issue in the Neth-erlands )e final questionnaire consisted of 11 items

32 Pretesting of the Questionnaire We pretested the 11items using think-aloud techniques on 7 adults 2 males and5 females with a mean age of 407 years with chronic painParticipants reported no difficulty comprehending thequestions but reported being surprised by the ldquovery tiredrdquoquestion as they were largely focused on pain Participantsalso reported having difficulty completing the questionnaireas they did not knowwhat to expect from pain rehabilitationdespite having had an educational group session on thecontent and goals of the pain rehabilitation programme

Second aim to describe the measurement properties ofthe translated treatment beliefs questionnaire including thepredictive validity for dropout

A total of 208 consecutive patients were asked to par-ticipate in this study before the start of the clinical baselineassessment of which 195 (94) signed informed consentSeven patients were excluded thereafter since they had nochronic musculoskeletal pain Data on internal consistencyand structural construct and predictive validity were col-lected at the baseline on 188 consecutive participants withchronic pain attending the chronic pain rehabilitationprogramme in the Heliomare Rehabilitation Centre )esample was 70 female with a mean (SD) age of 470 (12)years Mean (SD) pain intensity was 72 (15) Pain durationwas between 0 and 5 years for 505 of the sample and morethan 5 years for 383 of the sample Data were missing on112 of the sample )irty five participants (19) droppedout during treatment

In order to study reproducibility 51 participants wereincluded in rehabilitation centre ldquoDe Hoogstraatrdquo who


completed the treatment questionnaire twice )e samplehad a mean (SD) age of 429 (11) years and was 67 female)ere were no missing data for items 2 3 4 8 and 9 onemissing each for item 1 and items 6 7 10 and 11 and 4missings both for items 4 and 5 Participants at De Hoog-straat Rehabilitation Centre were statistically significantlyyounger than participants at Heliomare RehabilitationCentre (p 0037) Chi-square testing showed no significantdifference in gender between the sites (p 057) Chi-squaretesting also found no statistically significant differences initem distribution between the sites

33 Item-Level Analyses Descriptive analysis of the itemsdemonstrated good distribution of response options (ie useof the entire scale) across all items except the questionldquoAttending pain rehabilitation may help me to do moreactivitiesrdquo where no one scored ldquocompletely disagreerdquo Nofloor or ceiling effects were observed (see Table 1 fordistributions)

Two of the 188 participants (11) did not complete theTreatment Beliefs Questionnaire Missing items were notincluded in the analysis )ere were no missing items on theBrief IPQ or PSEQ

)e polychoric interitem correlations ranged betweenminus001 and 076 indicating little item redundancy (see Ta-ble 2) Only one high interitem correlation (076) was ob-served between the two transportation items but becausethese items inquire after different aspects of transportation(cost and availability) we decided to retain both items

34 Structural Validity )e exploratory factor analysis(EFA) showed all factors loading above 03 with items 1ndash6loading on one factor (necessity) items 7ndash9 loading on asecond factor (concerns) and items 10 and 11 loading on athird factor (practical barriers) As Q6 (some aspects of theprogramme may be harmful to me) loaded on necessitywhereas this item should belong to the concerns domainaccording to the literature we conducted two confirmatoryfactor analyses (CFA) to determine whichmodel had a betterfit

CFA based on the literature with Items 1ndash5 loading onnecessity 6ndash9 on concerns and items 10 and 11 on practicalbarriers showed a RMSEA 0077 CFI 09 GFI 092 andAGFI 087 )e CFA based on the EFA with items 1ndash6loading on necessity 7ndash9 on concerns and items 10 and 11loading on practical barriers showed a RMSEA 0064CFI 094 GFI 093 and AGFI 089 indicating a slightlybetter fit to the data for the latter model (see Table 3)

35 Internal Consistency Standardized ordinal alpha forpractical barriers was 087 For necessity ordinal alphawas 066 and for concerns α 066 We checked to see ifalpha for the domains would increase if an item wasdropped )is resulted in dropping the question aboutfatigue (item 9) from the concerns scale which raised theoverall alpha to 074

)e IPQ items and the treatment questionnaire domainswere not distributed normally therefore we computedSpearman correlations to test our hypotheses

We found small to medium associations between thethree domains High scores on necessity were related to lowscores on concerns (rs minus023) and we considered the as-sociation small High scores on concerns were associatedwith high scores on practical barriers (rs 030) High scoreson necessity domain were associated with low scores onpractical barriers (rs minus015)

36 Reproducibility Reproducibility data for the three do-mains of the Treatment Beliefs Questionnaire are presentedin Table 4

Quadratic weighted kappa for the items ranged from fairκ 035 for ldquoI have a clear picture of how pain rehabilitationwill help me resume my daily activitiesrdquo to substantialκ 072 for ldquoI am worried that I may not be able to keep upwith the exercise partrdquo

37 Construct Validity )e IPQ items and the treatmentquestionnaire domains were not distributed normallytherefore we computed Spearman correlations to test ourhypotheses

Higher scores on the necessity domain were associatedwith higher scores on the Brief IPQ treatment control item(rs 039) Higher scores on the concerns domain wereassociated with higher scores on the Brief IPQ concerns item(rs 034) Associations between concerns and IPQ conse-quences (rs 025) and IPQ emotional response (rs 025)were considered small Lower self-efficacy had a moderateassociation with higher scores on the concerns domain(rs minus041) )e associations (rs) between practical barriersand the IPQ items were all lt010 and considered negligible)ere was a small association between practical barriers andself-efficacy (PSEQ) rs minus017

38 Predictive Validity )irty-five (19) patients droppedout at different phases of the treatment 10 dropped out inthe diagnostic phase and 25 dropped out in the treatmentphase

For nondropouts the mean (SD) for necessity was 2237(30) concerns 49 (19) and practical barriers 359 (19) Fordropouts mean (SD) for necessity was 2221 (30) concerns503 (18) and practical barriers 426 (22) MannndashWhitneytesting revealed no statistically significant differences be-tween nondropouts and dropouts

To determine the predictive validity for dropout (yesno)of the treatment beliefs questionnaire we calculated a ROCcurve and the area under the curve (AUC) for each domain

)e AUC for necessity was 0515 (95 CI 040ndash063)with a standard error (SE) of 0057 For concerns AUC (SE)was 0522 (0053) 95 CI 042ndash063 and for practicalbarriers AUC (SE) was 0592 (0055) 95 CI 048ndash070 Asthe AUCs were poor and showed no predictive validity wedid not calculate sensitivity and specificity (Figures 1ndash3)


4 Discussion

)e first aim of the study was to translate and adapt theTreatment Beliefs Questionnaire as developed by Cooper et al[16] for Dutch patients with chronic pain attending in-terdisciplinary pain rehabilitation We did so in a 4 stepprocess which ultimately resulted in an 11 item questionnaire

)e perceived suitability questions from the originalquestionnaire were dropped as there was consensus thatthese questions were irrelevant to pain rehabilitation Onequestion of the practical barriers domain was dropped (ldquoitwould be financially difficult to take time off work to attendrehabilitationrdquo) as it was felt this is not an issue in theNetherlands

Table 2 Polychoric interitem correlations (n 188)

Question Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q111 I have a clear picture of how pain rehabilitation willhelp me resume my daily activities 10 041 022 minus017 011 minus024 minus019 minus010 002 minus002 001

2 I have a clear picture of what I want to achieve byattending pain rehabilitation 041 10 026 minus026 028 minus023 minus009 minus002 009 minus012 minus016

3 Attending pain rehabilitation may help me to domore activities 022 026 10 minus013 041 minus029 minus012 minus012 minus003 ndash020 minus015

4 Some aspects of pain rehabilitation are unnecessaryfor melowast minus017 minus026 minus013 10 minus015 033 020 017 011 010 017

5 I hope that attending pain rehabilitation may helpme to return to work quickly 011 028 041 minus015 10 minus020 minus014 minus013 004 minus006 minus009

6 Some aspects of pain rehabilitation may be harmfulto me minus024 minus023 minus029 033 minus020 10 030 024 003 027 027

7 I am worried that I may not be able to keep up withthe exercise part minus019 minus009 minus012 020 minus014 030 10 059 034 029 031

8 I may not be physically fit enough to attend painrehabilitation minus010 minus002 minus012 017 minus013 024 059 10 025 032 033

9 On the days between the rehabilitation sessions Iam probably very tired from exercising minus002 minus009 minus003 011 004 003 034 025 10 012 016

10 )e cost of transport may prevent me fromattending pain rehabilitation minus002 minus012 minus020 010 minus006 027 029 032 012 10 076

11 Availability of transport will influence mydecision to attend pain rehabilitation 001 minus016 minus015 017 minus009 027 031 033 016 076 10

Table 1 Item response option distributions in

Question Completely disagree Disagree Neutral Agree Completely agree Missing1 I have a clear picture of how pain rehabilitation willhelp me resume my daily activities

32 48 468 34 106 050 39 294 588 59 2

2 I have a clear picture of what I want to achieve byattending pain rehabilitation

11 27 309 511 138 050 20 176 569 235 0

3 Attending pain rehabilitation may help me to domore activities

0 21 112 505 356 050 20 137 549 294 0

4 Some aspects of pain rehabilitation are unnecessaryfor me

16 165 628 32 11 0520 20 510 255 118 78

5 I hope that attending pain rehabilitation may helpme to return to (volunteer) work quickly

53 16 388 303 234 0578 59 314 275 196 78

6 Some aspects of pain rehabilitation may be harmfulto me

319 255 372 37 05 11314 471 157 20 20 2

7 I am worried that I may not be able to keep up withthe exercise part

234 207 34 191 16 11235 392 196 137 20 20

8 I may not be physically fit enough to attend painrehabilitation

202 335 335 106 11 11294 412 216 78 0 0

9 On the days between the rehabilitation sessions Iam probably very tired from exercising

74 122 426 255 112 1178 216 392 255 59 0

10 )e cost of transport may prevent me fromattending pain rehabilitation

468 287 154 37 43 11588 333 20 20 20 2

11 Availability of transport will influence mydecision to attend pain rehabilitation

511 261 122 74 21 11588 333 39 20 0 0

Note In bold distribution from Heliomare (n 188) underneath the distribution from the Hoogstraat (n 51)


In the think-aloud study patients indicated being sur-prised by the ldquovery tiredrdquo item as they were largely focusedon pain We left the item in as it was deemed to be im-portant by their providers However in the statisticalanalysis we had to drop the item as it lowered the alpha onthe concerns subscale Participants indicated difficultycompleting the questionnaire as they did not quite knowwhat to expect from the pain programme despite themhaving had an educational session of 1 hour on the contentand purpose of the chronic pain rehabilitation programme)is was evidenced by the high number of ldquoneutralrdquo answerson for instance the ldquoSome aspects of the pain rehabilitationprogramme are unnecessary for merdquo item An exception wasitem 3 ldquoAttending pain rehabilitation may help me to domore activitiesrdquo where 86 of patients scored agree orcompletely agree which may be a reflection of the desiredoutcome of the chronic pain programme by patients

)e second aim of this study was to determine themeasurement properties of the Treatment Beliefs ques-tionnaire Structural validity testing revealed three subscales

(domains) representing necessity concerns and practicalbarriers In contrast to the original work by Cooper et al[16] we found that item 6 ldquosome aspects of the pain pro-gramme may be harmful to merdquo loaded better on the ne-cessity subscale than on the concerns subscale )is may bedue to the fact that about 96 of respondents scored dis-agree disagree completely or neutral indicating no par-ticular concerns about the potential harmfulness of the painprogramme )is was surprising given the body of knowl-edge on fear of movement in patients with chronic pain [41]

Internal consistency was fair to good with alphas rangingfrom 066ndash087)is is comparable to the findings by Fischeret al [17] and Cooper et al [16] Considering the lowinteritem correlations of the necessity subscale it is notsurprising that the internal consistency was only fair )ismay be an indication of dissimilar beliefs (on return to workdo more activities and necessity of parts of the pain pro-gramme) contributing to the necessity subscale

Reproducibility was acceptable with a small measure-ment error for both the necessity and concerns subscales

Table 4 Reproducibility Treatment Beliefs Questionnaire

Domains T1 (mean SD) T2 (mean SD) ICC2195 CI SEM SDCind

Necessity 2269 (254) 2328 (272) 0687050ndash081 177 492

Concerns 440 (177) 422 (162) 081069ndash089 091 255

Practical barriers 30 (141) 286 (125) 0665048ndash079 096 267

Note Replacing missing data by the mean score of the domains yielded the same results ICC21 two-way random effects intraclass correlation coefficientSEM standard error of measurement SDCind smallest detectable change for an individual

Table 3 Results of confirmatory factor analysis based on exploratory factor analysis

Loadings Factor 1 (necessity) Factor 2 (concerns) Factor 3 (practical barriers)1 I have a clear picture of how pain rehabilitation willhelp me resume my daily activities 0639 0 0

2 I have a clear picture of what I want to achieve byattending pain rehabilitation 0771 0 0

3 Attending pain rehabilitation may help me to domore activities 0683 0 0

4 Some aspects of pain rehabilitation are unnecessaryfor me minus0587 0 0

5 I hope that attending pain rehabilitation may helpme to return to (volunteer) work quickly 0567 0 0

6 Some aspects of pain rehabilitation may be harmfulto me minus0657 0 0

7 I am worried that I may not be able to keep up withthe exercise part 0 0926 0

8 I may not be physically fit enough to attend painrehabilitation 0 0733 0

9 On the days between the rehabilitation sessions Iam probably very tired from exercising 0 0450 0

10 )e cost of transport may prevent me fromattending pain rehabilitation 0 0 0861

11 Availability of transport will influence mydecision to attend pain rehabilitation 0 0 0954


Reproducibility of the practical barriers subscale was fairprobably due to the lack of heterogeneity of answers about75 of respondents answered disagree or completelydisagree

In testing our hypotheses for construct validity we foundsimilar size and consistent correlations in the same di-rection as Cooper et al [16] confirming construct validityPatients who perceived the pain programme as necessaryhad stronger beliefs in the treatment Patients with higher

concerns about the pain programme were more concernedabout their condition perceived their condition would last along time and were more affected emotionally Patients withlower pain self-efficacy had higher perceived concerns abouttreatment and higher perceived practical barriers

ROC analysis showed no predictive validity for dropoutwith AUClt 06 Fischer et al [17] also found no difference inparticipantsrsquo treatment beliefs between dropouts and par-ticipants who completed the programme Cooper et al [16]on the other hand found a significant difference in thenecessity beliefs subscale between those intending and notintending to participate in the (cardiac) rehabilitationprogramme before hospital discharge It is possible that theTreatment Beliefs Questionnaire is able to distinguish be-tween those who are referred to the pain programme andattend and those who are referred but do not attend )eTreatment Beliefs Questionnaire might help health pro-fessionals to identify patients who are likely not to attend theprogramme and who might need extra explanation beforethey are entered into the programme

)is is the first study on treatment beliefs using the NCFin a sample of Dutch participants attending pain re-habilitation It has been argued that the NCF might workwell for medication use [14] while for other treatmentsperceived credibility and treatment expectancy have beenconsidered more relevant [42 43] Treatment credibility hasbeen associated with outcomes in a combined physical andcognitive behavioural treatment in chronic low back pain[44] with dropout in an Internet-based cognitive behav-ioural relaxation programme [45] and a face-to-face andinternet-based cognitive behavioural therapy for bulimianervosa [46] Comparing the constructs of the NCF withtreatment credibility and expectancy could be subject forfurther study

00 02 04 06 08 1000

02

04

06

08

10

Sens

itivi

ty

1 ndash specificity

ROC curve

Figure 1 ROC curve of the domain concerns Diagonal segmentsare produced by ties

00 02 04 06 08 1000

02

04

06

08

10ROC curve

1 ndash specificity

Sens

itivi

ty

Figure 2 ROC curve of the domain necessity Diagonal segmentsare produced by ties

00 02 04 06 08 1000

02

04

06

08

10ROC curve

1 ndash specificitySe

nsiti

vity

Figure 3 ROC cure of the domain practical barriers Diagonalsegments are produced by ties


)ere are several limitations to this study )e same twotranslators conducted the forward and backwards trans-lation )is may be a source of bias Another limitation ofthis study is the location and time span for reproducibilitytesting For practical purposes we conducted the re-producibility study at the Hoogstraat Rehabilitation Centrewhile all other data were collected in the Heliomare Re-habilitation Centre Although the programmes are similarthere were some differences between participants as theparticipants in the Hoogstraat Rehabilitation Centre weresomewhat younger A time interval of about 2 weeks is oftenconsidered appropriate for the evaluation of reproducibilityof a patient reported outcome instrument if the patients arestable [30] To ensure that our participants remained stablewe tested before and after the one week where patientsunderwent further evaluation before treatment began Al-though participants had no insight into their earlier re-sponses recall bias cannot be excluded

5 Conclusion

We confirmed the structural validity of the Dutch trans-lation of the Treatment beliefs Questionnaire for chronicpain rehabilitation with three subscales necessity con-cerns and perceived barriers Internal consistency wasacceptable as was reproducibility Hypotheses testingconfirmed construct validity and predictive validity showedthe questionnaire was unable to predict dropouts Cross-cultural translation was successfully completed and theDutch Treatment Beliefs Questionnaire demonstratessimilar psychometric properties as the original Englishversion)is questionnaire may be a clinically useful tool toidentify patientsrsquo concerns about and possible barriers forchronic pain rehabilitation We recommend these arediscussed in the diagnostic phase of treatment to eliminateany possible concerns about and barriers for painrehabilitation

Data Availability

)e data used to support the findings of this study areavailable from the corresponding author upon reasonablerequest

Disclosure

)e views expressed are those of the authors and not thefunder

Conflicts of Interest

)e authors declare that they have no conflicts of interest

Acknowledgments

)e authors would like to thank Tom Dijkerman MScJolanda Hooijer MSc and Paul Westers MSc for theircontribution to this paper )is work was supported by agrant from SIA RAAK (2012-14-12P)

References

[1] D C Turk and A Okifuji ldquoTreatment of chronic pain pa-tients clinical outcomes cost-effectiveness and cost-benefitsof multidisciplinary pain centersrdquo Critical Reviews in Physicaland Rehabilitation Medicine vol 10 no 2 pp 181ndash208 1998

[2] G M Coughlan K L Ridout A C Williams andP H Richardson ldquoAttrition from a pain management pro-grammerdquo British Journal of Clinical Psychology vol 34 no 3pp 471ndash479 1995

[3] N Biller P Arnstein M A Caudill C W Federman andC Guberman ldquoPredicting completion of a cognitive-behav-ioral pain management program by initial measures of achronic pain patientrsquos readiness for changerdquo Clinical Journalof Pain vol 16 no 4 pp 352ndash359 2000

[4] J Oosterhaven H Wittink J Mollema C Kruitwagen andW Deville ldquoDropout still a neglected topic a systematicreview on predictors of dropout in interdisciplinary chronicpain rehabilitationrdquo Journal of Rehabilitation Medicinevol 51 pp 2ndash10 2019

[5] J Rainville D K Ahern and L Phalen ldquoAltering beliefs aboutpain and impairment in a functionally oriented treatmentprogram for chronic low back painrdquo Clinical Journal of Painvol 9 no 3 pp 196ndash201 1993

[6] H Leventhal D Nerenz and D J Steele ldquoIllness represen-tations and coping with health threatsrdquo in Handbook ofPsychology and Health A Baum S E Taylor and J E SingerEds pp 219ndash252 Lawrence Erlbaum Associates HillsdaleNJ USA 4th edition 1984

[7] H Leventhal ldquoIllness representations theoretical founda-tionsrdquo in Perceptions of Health and Illness Current Researchand Applications K J Petrie and J Weinmann Edspp 19ndash45 Amsterdam Harwood Academic AmsterdamNetherlands 1997

[8] H Leventhal L A Phillips and E Burns ldquo)e common-sense model of self-regulation (CSM) a dynamic frameworkfor understanding illness self-managementrdquo Journal of Be-havioral Medicine vol 39 no 6 pp 935ndash946 2016

[9] J Weinman and K J Petrie ldquoIllness perceptions a newparadigm for psychosomaticsrdquo Journal of psychosomaticresearch vol 42 no 2 pp 113ndash116 1997

[10] R Horne S C E Chapman R Parham N FreemantleA Forbes and V Cooper ldquoUnderstanding patientsrsquo adher-ence-related beliefs about medicines prescribed for long-termconditions a meta-analytic review of the Necessity-ConcernsFrameworkrdquo PLoS One vol 8 no 12 Article ID e80633 2013

[11] K Brandes and B Mullan ldquoCan the common-sense modelpredict adherence in chronically ill patients A meta-analy-sisrdquoHealth Psychology Review vol 8 no 2 pp 129ndash153 2014

[12] N Aujla M Walker N Sprigg K Abrams A Massey andK Vedhara ldquoCan illness beliefs from the common-sensemodel prospectively predict adherence to self-managementbehaviours A systematic review and meta-analysisrdquo Psy-chology amp Health vol 31 no 8 pp 931ndash958 2016

[13] R Horne ldquoRepresentations of medication and treatmentAdvances in theory and measurementrdquo in Perceptions ofIllness and Health Current Research and ApplicationsK Petrie and J Weinman Eds pp 155ndash187 Harwood Ac-ademic London UK 1997

[14] R Horne and J Weinman ldquoPatientsrsquo beliefs about prescribedmedicines and their role in adherence to treatment in chronicphysical illnessrdquo Journal of Psychosomatic Research vol 47no 6 pp 555ndash567 1999


[15] M Glattacker K Heyduck and C Meffert ldquoIllness beliefs andtreatment beliefs as predictors of short-term and medium-term outcome in chronic back painrdquo Journal of RehabilitationMedicine vol 45 no 3 pp 268ndash276 2013

[16] A F Cooper J Weinman M Hankins G Jackson andR Horne ldquoAssessing patientsrsquo beliefs about cardiac re-habilitation as a basis for predicting attendance after acutemyocardial infarctionrdquo Heart vol 93 no 1 pp 53ndash58 2007

[17] M J Fischer M Scharloo J Abbink et al ldquoConcerns aboutexercise are related to walk test results in pulmonary re-habilitation for patients with COPDrdquo International Journal ofBehavioral Medicine vol 19 no 1 pp 39ndash47 2012

[18] R S Bucks K Hawkins T C Skinner S Horn P Seddonand R Horne ldquoAdherence to treatment in adolescents withcystic fibrosis the role of illness perceptions and treatmentbeliefsrdquo Journal of Pediatric Psychology vol 34 no 8pp 893ndash902 2009

[19] R Sohanpal L Steed T Mars and S J C Taylor ldquoUn-derstanding patient participation behaviour in studies ofCOPD support programmes such as pulmonary rehabilitationand self-management a qualitative synthesis with applicationof theoryrdquo NPJ Primary Care Respiratory Medicine vol 25no 1 article 15054 2015

[20] A F Cooper G Jackson J Weinman and R Horne ldquoAqualitative study investigating patientsrsquo beliefs about cardiacrehabilitationrdquo Clinical Rehabilitation vol 19 no 1 pp 87ndash96 2005

[21] World Medical Association ldquoWorld Medical AssociationDeclaration of Helsinki ethical principles for medical re-search involving human subjectsrdquo JAMA vol 310 no 20pp 2191ndash2194 2013

[22] E Broadbent K J Petrie J Main and J Weinman ldquo)e briefillness perception questionnairerdquo Journal of PsychosomaticResearch vol 60 no 6 pp 631ndash637 2006

[23] M K Nicholas ldquo)e pain self-efficacy questionnaire takingpain into accountrdquo European Journal of Pain vol 11 no 2pp 153ndash163 2007

[24] E J de Raaij C Schroder F J Maissan J J Pool andH Wittink ldquoCross-cultural adaptation and measurementproperties of the brief illness perception questionnaire-dutchlanguage versionrdquo Manual gterapy vol 17 no 4 pp 330ndash335 2012

[25] L C C van derMaas H CW de Vet A Koke R J Bosscherand M L Peters ldquoPsychometric properties of the pain self-efficacy questionnaire (PSEQ)rdquo European Journal of Psy-chological Assessment vol 28 no 1 pp 68ndash75 2012

[26] R Core Team A Language and Environment for StatisticalComputing R Core Team Vienna Austria 2014

[27] K G Joreskog and D A Sorbom LISREL 854 and PRELIS254 Scientific Software Chicago IL USA 2006

[28] M G Bulmer Principles of Statistics (Dover) Dover NewYork NY USA 1979

[29] J A Ekstrom Generalized Definition of the Polychoric Cor-relation Coefficient pp 1ndash24 Department of Statistics UCLALos Angeles CA USA 2011

[30] D Streiner and G Norman Health Measurement Scales APractical Guide to gteir Development and Use Oxford Uni-versity Press New York NY USA 1991

[31] L-T Hu and P M Bentler ldquoFit indices in covariancestructure modeling sensitivity to underparameterized modelmisspecificationrdquo Psychological Methods vol 3 no 4pp 424ndash453 1998

[32] L T Hu and P M Bentler ldquoCutoff criteria for fit indexes incovariance structure analysis conventional criteria versus

new alternativesrdquo Structural Equation Modeling A Multi-disciplinary Journal vol 6 no 1 pp 1ndash55 1999

[33] H Baumgartner and C Homburg ldquoApplications of structuralequation modeling in marketing and consumer research areviewrdquo International Journal of Research in Marketingvol 13 no 2 pp 139ndash161 1996

[34] B D Zumbo A M Gadermann and C Zeisser ldquoOrdinalversions of coefficients alpha and theta for Likert ratingscalesrdquo Journal of Modern Applied Statistical Methods vol 6no 1 pp 21ndash29 2007

[35] J C Nunnaly Psychometric gteory McGraw-Hill New YorkNY USA 2nd edition 1978

[36] J R Landis and G G Koch ldquo)e measurement of observeragreement for categorical datardquo Biometrics vol 33 no 1pp 159ndash174 1977

[37] J Cohen Statistical Power Analysis for the Behavioral SciencesLawrence Earlbaum Associates Hillsdale NJ USA 2ndedition 1988

[38] C B Terwee S D M Bot M R de Boer et al ldquoQualitycriteria were proposed for measurement properties of healthstatus questionnairesrdquo Journal of Clinical Epidemiologyvol 60 no 1 pp 34ndash42 2007

[39] J Cohen Statistical Power Analysis for the Behavioral SciencesLawrence Erlbaum Associates Hillsdale NJ USA 2nd edi-tion 1988

[40] D E Beaton C Bombardier F Guillemin and M B FerrazldquoGuidelines for the process of cross-cultural adaptation ofself-report measuresrdquo Spine vol 25 no 24 pp 3186ndash31912000

[41] J W S Vlaeyen and S J Linton ldquoFear-avoidance and itsconsequences in chronic musculoskeletal pain a state of theartrdquo Pain vol 85 no 3 pp 317ndash332 2000

[42] G J Devilly and T D Borkovec ldquoPsychometric properties ofthe credibilityexpectancy questionnairerdquo Journal of Behaviorgterapy and Experimental Psychiatry vol 31 no 2 pp 73ndash862000

[43] A Dima G T Lewith P Little et al ldquoPatientsrsquo treatmentbeliefs in low back painrdquo Pain vol 156 no 8 pp 1489ndash15002015

[44] R J E M Smeets S Beelen M E J B GoossensE G W Schouten J A Knottnerus and J W S VlaeyenldquoTreatment expectancy and credibility are associated with theoutcome of both physical and cognitive-behavioral treatmentin chronic low back painrdquo Clinical Journal of Pain vol 24no 4 pp 305ndash315 2008

[45] S Alfonsson E Olsson and T Hursti ldquoMotivation andtreatment credibility predicts dropout treatment adherenceand clinical outcomes in an internet-based cognitive behav-ioral relaxation program a randomized controlled trialrdquoJournal of Medical Internet Research vol 18 no 3 p e522016

[46] H J Watson M D Levine S C Zerwas et al ldquoPredictors ofdropout in face-to-face and internet-based cognitive-behav-ioral therapy for bulimia nervosa in a randomized controlledtrialrdquo International Journal of Eating Disorders vol 50 no 5pp 569ndash577 2017


Stem Cells International

Hindawiwwwhindawicom Volume 2018


MEDIATORSINFLAMMATION

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EndocrinologyInternational Journal of



Disease Markers


BioMed Research International

OncologyJournal of



Oxidative Medicine and Cellular Longevity


PPAR Research

Hindawi Publishing Corporation httpwwwhindawicom Volume 2013Hindawiwwwhindawicom

The Scientific World Journal

Volume 2018

Immunology ResearchHindawiwwwhindawicom Volume 2018

Journal of

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Computational and Mathematical Methods in Medicine


Behavioural Neurology

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Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary andAlternative Medicine

Volume 2018Hindawiwwwhindawicom

Submit your manuscripts atwwwhindawicom

According to the common sense model of self-regulation(CSM) [6ndash8] patients develop beliefs about their conditionor illness which influence the interpretation of informationand experiences and which guide behaviour [9] Patientstherefore bring preexisting beliefs about their illness andtreatment (illness representations and treatment represen-tations) to pain rehabilitation which influence their eval-uation of the treatment their adherence and even beneficialor adverse outcomes [10] Several meta-analyses howeverhave shown a very weak relationship between individualillness beliefs and adherence in patients with chronic dis-eases [11 12] Aujla et al [12] report that an aspect of theCSM that has not been captured by their review because of alack of availability of data from included papers concernstreatment beliefs Beliefs about medications is one of the fewtreatment representations that have been studied system-atically [8] Research conducted with patients with a varietyof long-term conditions suggests that the key beliefsinfluencing patientsrsquo common sense evaluations of pre-scribed medicines can be grouped under two categoriesperceptions of personal need for treatment (necessity beliefs)and concerns about a range of potential adverse conse-quences [10 13 14] )is ldquoNecessity-Concerns Framework(NCF)rdquo potentially offers a convenient model for cliniciansto elicit and address key beliefs underpinning patientsrsquo at-titudes and decisions about treatment [10] A recent meta-analytic review of the NCF about medicines prescribed forlong-term conditions showed that higher adherence wasassociated with stronger perceptions of necessity of treat-ment and fewer concerns about treatment [10]

Compared to the body of evidence on treatment beliefsabout medication there is scant information on treatmentbeliefs about rehabilitation Beliefs about rehabilitation havebeen shown to make a significant contribution to the pre-diction of rehabilitation outcomes in one study [15] andthey are thought to strongly influence adherence to treat-ment [10 14] )e Treatment Beliefs Questionnaire wasinitially developed as basis for predicting cardiac re-habilitation attendance after acute myocardial infarction)is 13 item questionnaire had good structural validity withinternal consistencies gt07 for all domains resulting inacceptable construct validity [16] An adapted version wasused in elderly patients with COPD to test the associationbetween treatment beliefs and baseline test performance andresponse to treatment [17] For pain rehabilitation no suchquestionnaire exists even though treatment beliefs appear tobe important in predicting adherence to treatment ordropout of patients with chronic pain entering an in-terdisciplinary pain rehabilitation programme Severalstudies investigating adherence to cystic fibrosis chronicobstructive pulmonary disease (COPD) and cardiac re-habilitation programmes have found that patients whoexpressed concerns about the programme or who reportedpractical barriers to attendance were less likely to attend[16ndash19]

Our first aim was to translate and adapt a questionnairebased on the NCF initially developed and validated forcardiac rehabilitation research [16 20] later adapted andvalidated for use in an elderly COPD population [17] for

patients attending interdisciplinary pain rehabilitationprogrammes Our second aim was to describe the mea-surement properties of the translated and adapted treatmentbeliefs questionnaire including the predictive validity fordropout

2 Methods

21 Participant Recruitment Consecutive patients withchronic noncancer pain who were referred to one of tworehabilitation centres (Heliomare Wijk aan Zee and DeHoogstraat Revalidatie Utrecht the Netherlands) wereinvited to participate during the intake phase betweenOctober 2012 and October 2016 All participants providedinformed consent and gave researchers permission toobtain sociodemographic and medical information fromtheir medical records Both rehabilitation centres con-ducted comparable interdisciplinary pain managementprogrammes for patients with chronic pain consisting ofcognitive behavioural therapy with pain neuroeducationand exercise therapy Patients who were judged appropriatecandidates for the interdisciplinary programme by either aphysiatrist (Heliomare) or a physiatrist pain consultantand a psychologist (Hoogstraat) were entered into theprogramme to start an initial period of assessment (di-agnostic phase) by the other members of the team (psy-chologist physical therapist occupational therapist socialworker sport professional and music therapist) in order tocome to an appropriate treatment plan (treatment phase)Excluded from the study were participants who were un-able to read or write Dutch

)e study was registered with the Medical EthicsCommittee of the Academic Medical Centre of Amsterdamwhich declared that it did not fall under the scope of theldquoMedical Research Involving Human Subjects Actrdquo and bythe internal research ethics review boards of the two re-habilitation centres All patients provided written informedconsent and were treated in accordance to the declaration ofHelsinki [21]

22 Materials )e treatment beliefs questionnaire wasdeveloped by Cooper et al [16] for patients referred tocardiac rehabilitation based on the results from interviewstudies consistent with the NCF [20] )e questionnaireconsists of 13 items across 4 domains necessity (5 items)concerns (3 items) practical barriers (3 items) and per-ceived personal suitability (2 items) Internal consistency ofthe 4 domains varied between Cronbachrsquos α 070 forpractical barriers and α 079 for concerns Items are scoredon a 5-point Likert scale from 1 strongly disagree to 5strongly agree Higher scores on the necessity subscale in-dicate the patient is more likely to perceive treatment asnecessary and to be clear as to how it will benefit Higherscores on the concerns subscale indicate the patient hasconcerns about participating in treatment Higher scores onpractical barriers indicate there might be practical barriers toparticipating in treatment A higher score on perceivedpersonal suitability indicates a greater belief that (cardiac)

















(1minus ICC)



2






3 Results



























4 Discussion

















32 48 468 34 106 050 39 294 588 59 2


11 27 309 511 138 050 20 176 569 235 0


0 21 112 505 356 050 20 137 549 294 0


16 165 628 32 11 0520 20 510 255 118 78


53 16 388 303 234 0578 59 314 275 196 78


319 255 372 37 05 11314 471 157 20 20 2


234 207 34 191 16 11235 392 196 137 20 20


202 335 335 106 11 11294 412 216 78 0 0


74 122 426 255 112 1178 216 392 255 59 0


468 287 154 37 43 11588 333 20 20 20 2


511 261 122 74 21 11588 333 39 20 0 0










Necessity 2269 (254) 2328 (272) 0687050ndash081 177 492

Concerns 440 (177) 422 (162) 081069ndash089 091 255





















00 02 04 06 08 1000

02

04

06

08

10

Sens

itivi

ty

1 ndash specificity

ROC curve


00 02 04 06 08 1000

02

04

06

08

10ROC curve

1 ndash specificity

Sens

itivi

ty


00 02 04 06 08 1000

02

04

06

08

10ROC curve


nsiti

vity




5 Conclusion


Data Availability


Disclosure




Acknowledgments


References






















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of


































(1minus ICC)



2






3 Results



























4 Discussion

















32 48 468 34 106 050 39 294 588 59 2


11 27 309 511 138 050 20 176 569 235 0


0 21 112 505 356 050 20 137 549 294 0


16 165 628 32 11 0520 20 510 255 118 78


53 16 388 303 234 0578 59 314 275 196 78


319 255 372 37 05 11314 471 157 20 20 2


234 207 34 191 16 11235 392 196 137 20 20


202 335 335 106 11 11294 412 216 78 0 0


74 122 426 255 112 1178 216 392 255 59 0


468 287 154 37 43 11588 333 20 20 20 2


511 261 122 74 21 11588 333 39 20 0 0










Necessity 2269 (254) 2328 (272) 0687050ndash081 177 492

Concerns 440 (177) 422 (162) 081069ndash089 091 255





















00 02 04 06 08 1000

02

04

06

08

10

Sens

itivi

ty

1 ndash specificity

ROC curve


00 02 04 06 08 1000

02

04

06

08

10ROC curve

1 ndash specificity

Sens

itivi

ty


00 02 04 06 08 1000

02

04

06

08

10ROC curve


nsiti

vity




5 Conclusion


Data Availability


Disclosure




Acknowledgments


References






















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of





































4 Discussion

















32 48 468 34 106 050 39 294 588 59 2


11 27 309 511 138 050 20 176 569 235 0


0 21 112 505 356 050 20 137 549 294 0


16 165 628 32 11 0520 20 510 255 118 78


53 16 388 303 234 0578 59 314 275 196 78


319 255 372 37 05 11314 471 157 20 20 2


234 207 34 191 16 11235 392 196 137 20 20


202 335 335 106 11 11294 412 216 78 0 0


74 122 426 255 112 1178 216 392 255 59 0


468 287 154 37 43 11588 333 20 20 20 2


511 261 122 74 21 11588 333 39 20 0 0










Necessity 2269 (254) 2328 (272) 0687050ndash081 177 492

Concerns 440 (177) 422 (162) 081069ndash089 091 255





















00 02 04 06 08 1000

02

04

06

08

10

Sens

itivi

ty

1 ndash specificity

ROC curve


00 02 04 06 08 1000

02

04

06

08

10ROC curve

1 ndash specificity

Sens

itivi

ty


00 02 04 06 08 1000

02

04

06

08

10ROC curve


nsiti

vity




5 Conclusion


Data Availability


Disclosure




Acknowledgments


References






















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of


























Necessity 2269 (254) 2328 (272) 0687050ndash081 177 492

Concerns 440 (177) 422 (162) 081069ndash089 091 255





















00 02 04 06 08 1000

02

04

06

08

10

Sens

itivi

ty

1 ndash specificity

ROC curve


00 02 04 06 08 1000

02

04

06

08

10ROC curve

1 ndash specificity

Sens

itivi

ty


00 02 04 06 08 1000

02

04

06

08

10ROC curve


nsiti

vity




5 Conclusion


Data Availability


Disclosure




Acknowledgments


References






















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of
























00 02 04 06 08 1000

02

04

06

08

10

Sens

itivi

ty

1 ndash specificity

ROC curve


00 02 04 06 08 1000

02

04

06

08

10ROC curve

1 ndash specificity

Sens

itivi

ty


00 02 04 06 08 1000

02

04

06

08

10ROC curve


nsiti

vity




5 Conclusion


Data Availability


Disclosure




Acknowledgments


References






















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of




















5 Conclusion


Data Availability


Disclosure




Acknowledgments


References






















































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of

























































of




Disease Markers



OncologyJournal of





PPAR Research



Volume 2018


Journal of

ObesityJournal of



















dutchtranslationandadaptationofthetreatmentbeliefs...

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