Multidimensional Pain Readiness to Change Questionnaire 2 (13&26 items)

1. Abstract

The Multidimensional Pain Readiness to Change Questionnaire 2 (13&26 items)—commonly designated as the MPRCQ2-13 and MPRCQ2-26—represents a refined, psychometrically robust self-report measurement suite designed to quantify an individual’s motivational readiness to adopt active self-management behaviors for chronic pain. Derived from the conceptual architecture of the Transtheoretical Model (TTM) of Health Behavior Change formulated by James O. Prochaska and Carlo C. DiClemente, and adapted for persistent pain conditions by Warren R. Nielson and colleagues, these shortened instruments address the clinical necessity for rapid, low-burden assessment in multidisciplinary rehabilitation environments. The original Dutch translations and shortened adaptations formalized by Paul van Burken (2009) systematically condense the comprehensive original battery into practical 26-item and 13-item inventories, respectively.

Both instruments operationalize readiness across four core stages of behavioral change: Precontemplation, Contemplation, Action, and Maintenance (frequently integrating or juxtaposing Preparation depending on structural modeling). These developmental stages are mapped across primary evidence-based pain self-management domains, specifically: regular exercise and movement therapy, activity pacing, physiological relaxation techniques, and cognitive-affective coping strategies. Items are scored on a standardized 7-point Likert response scale, anchored from 1 (“Strongly Disagree”) to 7 (“Strongly Agree”). Extensive psychometric evaluations demonstrate that both the 26-item and 13-item variants exhibit sound internal consistency, with Cronbach’s alpha coefficients across discrete stage subscales routinely exceeding α = .70 to .88, satisfactory test-retest reliability, robust convergent validity with measures of pain self-efficacy, acceptance, and catastrophizing, and strong predictive utility regarding multidisciplinary treatment engagement, physical therapy adherence, and functional recovery trajectories.

2. Keywords

Multidimensional Pain Readiness to Change Questionnaire, MPRCQ2, chronic pain, Transtheoretical Model, stages of change, pain self-management, activity pacing, physical rehabilitation, psychometrics, treatment adherence

3. Authors

The theoretical and empirical lineage of the Multidimensional Pain Readiness to Change Questionnaire 2 (13&26 items) spans foundational developments in health psychology, pain medicine, and Dutch rehabilitation science:

• Warren R. Nielson, Ph.D. — Principal Architect of the original MPRCQ and MPRCQ2. Lawson Health Research Institute, B&J Institute, St. Joseph’s Health Care London, and Departments of Medicine and Psychology, The University of Western Ontario, London, Ontario, Canada.
• Paul van Burken, PT, MSc — Developer of the Dutch translation and shortened clinical adaptations (MPRCQ2-13 and MPRCQ2-26, 2009); specialist in physical therapy, pain neuroscience education, and movement rehabilitation in chronic musculoskeletal disorders, the Netherlands.
• Collaborating Theoretical Contributors: Derived from foundational models created by James O. Prochaska, Ph.D., and Carlo C. DiClemente, Ph.D. (American Psychological Association fellows and originators of the Transtheoretical Model).

4. Purpose

The transition from an acute biomedical paradigm to a biopsychosocial rehabilitation framework represents the fundamental challenge of modern chronic pain management. Persistent non-cancer pain conditions—including fibromyalgia, chronic low back pain, complex regional pain syndrome, and generalized myofascial pain syndromes—rarely respond to passive curative interventions such as pharmacotherapy, surgery, or passive electrophysical modalities. Instead, clinical guidelines uniformly mandate active patient engagement through self-management regimens comprising graded physical exercise, ergonomic activity pacing, physiological relaxation, and cognitive reappraisal.

Despite the established clinical efficacy of active rehabilitation, patient non-adherence and premature program termination remain substantial clinical hurdles. Attrition rates in multidisciplinary chronic pain programs historically fluctuate between 20% and 50%. A primary determinant of treatment failure is motivational incongruence: rehabilitation clinicians frequently deliver action-oriented self-management therapies to individuals who remain psychologically situated within pre-action stages of change. Patients in a precontemplative state typically attribute pain resolution solely to external medical professionals and view behavioral recommendations as irrelevant or invalidating.

The primary clinical and empirical purpose of the MPRCQ2-13 and MPRCQ2-26 is to accurately quantify a patient’s behavioral readiness to adopt specific active self-management modalities prior to or during therapeutic intervention. Rather than treating “motivation” as a monolithic, static trait, these instruments diagnose dynamic, domain-specific motivational phases. For instance, an individual may present in the Action stage regarding physical exercise, yet remain entrenched in Precontemplation regarding cognitive reframing or pacing.

Clinically, the administration of the MPRCQ2-13 or MPRCQ2-26 serves multiple purposes:

• Stage-Matched Treatment Prescription: Clinicians can identify whether a patient requires psychoeducation and motivational interviewing to address ambivalence (Precontemplation/Contemplation) or structured behavioral skill training (Preparation/Action).
• Triage and Resource Allocation: Multidisciplinary pain clinics utilize these measures to allocate intensive, costly rehabilitation programs to patients possessing the requisite motivational baseline, while offering targeted motivational pre-habilitation to those at risk of program drop-out.
• Monitoring Longitudinal Shifts: Administering the scale at intake, mid-treatment, and discharge enables empirical tracking of cognitive transitions from external medical dependence to internal self-efficacy and behavioral mastery.
• Empirical Research Standardization: In clinical trials, the scale serves as an essential moderator or mediator variable, accounting for variance in treatment responsiveness across heterogeneous chronic pain cohorts.

5. Psychological Construct

The psychological construct evaluated by the MPRCQ2-13 and MPRCQ2-26 is readiness to change within the context of persistent pain self-management. This construct represents an integration between cognitive disposition, affective appraisal, behavioral intention, and overt behavioral execution. Rooted in social cognitive theory and motivational psychology, readiness to change assumes that lifestyle modification is neither an all-or-nothing phenomenon nor a fixed personality trait. Rather, it operates as an evolving, multi-tiered process characterized by qualitative shifts in intentionality, perceived behavioral control, and decisional balance.

The Transtheoretical Stages Operationalized in Pain Management

The questionnaires operationalize the dynamic movement across distinct stages of change, tailored specifically to non-cancer chronic pain behaviors:

• Precontemplation: Characterized by the absolute absence of intention to adopt active behavioral self-management within the foreseeable future (typically framed as the next six months). Patients within this stage attribute total responsibility for pain mitigation to external agents (surgeons, physical therapists, medications). They often perceive behavioral advice—such as engaging in daily stretching or stress management—as an implicit accusation that their physical suffering is imaginary or psychogenic.
• Contemplation: Marked by profound ambivalence. Individuals in contemplation recognize that their persistent pain requires long-term behavioral adaptation and acknowledge the prospective utility of self-management strategies. However, the perceived burdens, physical discomfort, and logistical barriers are viewed as roughly equal to the prospective benefits. Patients may remain immobilized in this phase for extended periods, contemplating lifestyle modifications without executing concrete steps.
• Preparation / Action: In the preparation phase, individuals intend to initiate behavioral changes within the immediate future (e.g., the upcoming month) and often display minor exploratory adjustments. In the overt Action stage, individuals actively alter their behavioral patterns, consistently executing prescribed physical exercises, restructuring daily pacing routines, practicing mindfulness or progressive muscle relaxation, and reframing catastrophizing cognitions. This stage requires significant expenditure of cognitive, physical, and emotional resources.
• Maintenance: Represents the continuous, long-term stabilization of active self-management behaviors (conventionally defined as sustained adherence beyond six months). The focal psychological task shifts from initiating novel behaviors to relapse prevention, integrating coping skills during acute pain flare-ups, and consolidating self-management into one’s habitual lifestyle and identity.

Targeted Behavioral Domains

Unlike unidimensional readiness scales that evaluate overall readiness to “manage pain,” the MPRCQ framework is inherently multidimensional. It isolates four distinct self-management competencies:

1. Physical Activity and Graded Exercise: The commitment to perform routine stretching, strengthening, and aerobic activities designed to mitigate deconditioning, overcome kinesiophobia, and restore physical function.
2. Activity Pacing: The behavioral capacity to regulate energy expenditure, alternating between structured intervals of activity and scheduled rest, thereby avoiding the maladaptive “boom-and-bust” cycle common in persistent pain disorders.
3. Physiological Relaxation and Stress Reduction: The consistent deployment of psychophysiological downregulation techniques, such as diaphragmatic breathing, autogenic training, or guided imagery, to modulate sympathetic nervous system hyperarousal.
4. Cognitive Coping and Reappraisal: The deliberate application of cognitive-behavioral strategies to identify, challenge, and reframe catastrophic interpretations of nociception, pain-related distress, and somatic sensations.

6. Theoretical Framework

The foundational architecture of the MPRCQ instruments rests at the intersection of the Transtheoretical Model (TTM), the Biopsychosocial Model of illness, and Bandura’s Social Cognitive Theory.

The Transtheoretical Paradigm (Prochaska & DiClemente)

Originally formulated to explain intentional cessation behaviors in substance dependence and smoking, the TTM posits that health behavior transformation occurs across temporal, cyclical stages rather than linear trajectories. When transposing this framework to chronic pain, Nielson and colleagues recognized an essential conceptual distinction: whereas addictive behaviors require the cessation of a maladaptive action, chronic pain rehabilitation requires the acquisition and lifelong maintenance of complex, effortful self-regulatory behaviors in the presence of physical discomfort.

The TTM operates through three interactive structural dimensions:

• Stages of Change: The temporal and motivational milestones (Precontemplation, Contemplation, Preparation, Action, Maintenance) that demarcate an individual’s psychological positioning.
• Decisional Balance: Conceptualized through the work of Janis and Mann, decisional balance reflects the individual’s cognitive weighing of the “Pros” (perceived functional gains, autonomy, reduced disability) versus the “Cons” (exacerbated transient soreness, time constraints, financial expenditure, surrender of biomedical cure expectations) of adopting active self-management. Transition from Precontemplation to Action demands that the perceived pros decisively outweigh the cons.
• Processes of Change: The covert cognitive-affective shifts (e.g., consciousness-raising, dramatic relief, environmental reevaluation) and overt behavioral techniques (e.g., stimulus control, counterconditioning, reinforcement management) that propel the individual forward through the stages.

Biopsychosocial and Social Cognitive Integration

The instrument incorporates Albert Bandura’s construct of self-efficacy—the subjective belief in one’s personal capability to organize and execute courses of action required to manage prospective situations. In chronic pain, self-efficacy acts as a gatekeeper of behavioral change. Patients who express high readiness (Action/Maintenance) consistently display elevated pain self-efficacy, whereas those in Precontemplation report low self-efficacy coupled with high external locus of control.

Furthermore, the MPRCQ reflects Engel’s Biopsychosocial Model, which posits that biological nociception is filtered through psychological vulnerabilities, appraisals, and social contexts. The short forms (MPRCQ2-13 and MPRCQ2-26) quantify the psychological transition from treating chronic pain as an exclusively biomedical disease to managing it as a multifaceted, long-term condition requiring continuous personal agency.

7. Validity

The validity of the MPRCQ2-26 and its ultra-short counterpart, the MPRCQ2-13, has been rigorously substantiated through multiple empirical investigations within tertiary pain clinics, outpatient rehabilitation centers, and specialized physical therapy settings.

Construct and Structural Validity

Construct validity has been established by evaluating whether the instruments accurately mirror the theoretical architecture of the Transtheoretical Model. Confirmatory factor analytic investigations consistently support the multi-stage, multidimensional framework. The correlations among subscales adhere closely to a simplex pattern: adjacent stages of change (e.g., Contemplation and Action) demonstrate moderate positive correlations, whereas non-adjacent stages (e.g., Precontemplation and Action, or Precontemplation and Maintenance) exhibit strong negative or orthogonal correlations ($r = -.35$ to $-.58$, $p < .001$). This structural coherence confirms that the instruments measure distinct points along a motivational continuum.

Convergent and Discriminant Validity

Extensive studies examining convergent validity demonstrate predictable relationships between MPRCQ2 subscales and validated psychological instruments:

• Pain Catastrophizing: As measured by the Pain Catastrophizing Scale (PCS), catastrophizing cognitions correlate positively with the Precontemplation subscale ($r = .32$ to $.45$) and negatively with Action and Maintenance subscales ($r = -.28$ to $-.41$). Individuals who ruminate excessively on pain sensations typically reject self-management principles.
• Pain Acceptance: Measured via the Chronic Pain Acceptance Questionnaire (CPAQ), pain acceptance shares robust positive associations with the Action and Maintenance stages ($r = .48$ to $.62$) and significant inverse associations with Precontemplation ($r = -.51$).
• Pain Self-Efficacy: Evaluations utilizing the Pain Self-Efficacy Questionnaire (PSEQ) demonstrate that patients scoring high on Action/Maintenance display significantly greater confidence in their ability to perform daily tasks despite pain ($r = .44$ to $.56$).
• Depression and Somatization: Administered alongside instruments such as the Beck Depression Inventory (BDI-II) or the SCL-90-R, Precontemplation shows moderate positive correlations with depressive symptomatology, reflecting clinical demoralization and learned helplessness.

Predictive and Criterion Validity

Criterion-related validity is highlighted by the scale’s ability to forecast clinical outcomes in interdisciplinary pain treatment:

• Baseline Action and Maintenance scores significantly predict session attendance, programmatic completion, and active compliance with home-based exercise protocols ($R^2$ variance explained ranging between 14% and 22%).
• Elevated baseline Precontemplation scores serve as an independent statistical predictor of premature treatment dropout and poor functional restoration, even after adjusting for baseline pain intensity, demographic variables, and duration of symptoms.
• Longitudinal investigations demonstrate that patients who exhibit significant forward stage progression (e.g., migrating from Precontemplation to Contemplation, or from Contemplation to Action) over the course of multidisciplinary rehabilitation achieve significantly greater reductions in interference on the Brief Pain Inventory (BPI) and marked reductions in healthcare utilization at 6- and 12-month follow-ups.

8. Reliability

Both the MPRCQ2-26 and the MPRCQ2-13 exhibit psychometric reliability across heterogeneous clinical populations suffering from persistent non-malignant pain.

Internal Consistency

The internal consistency of the stage subscales has been evaluated extensively using Cronbach’s coefficient alpha (α) and McDonald’s omega (ω):

• MPRCQ2-26: Across multiple international clinical cohorts, the 26-item edition demonstrates good to excellent internal consistency across its constituent subscales:
  • Precontemplation Subscale: α values consistently span .76 to .84.
  • Contemplation Subscale: α values range between .74 and .83.
  • Action Subscale: α values reliably demonstrate high homogeneity, typically ranging from .82 to .89.
  • Maintenance Subscale: α values range from .80 to .87.
• MPRCQ2-13: Despite the significant reduction in item density designed to minimize patient burden, the 13-item abbreviated tool retains acceptable to good reliability parameters:
  • Subscale alphas generally range from α = .70 to .82.
  • While ultra-short measures often experience structural attenuation of Cronbach’s alpha due to fewer items per factor, the inter-item correlations maintain moderate-to-high coherence ($r = .35$ to $.55$), confirming that measurement fidelity is preserved.

Test-Retest Reliability and Stability

Temporal stability evaluated over a two-to-three-week test-retest window in stable, untreated chronic pain outpatients indicates acceptable intraclass correlation coefficients (ICCs), typically ranging from $.73$ to $.86$. In accordance with theoretical expectations, when patients undergo active clinical interventions such as motivational interviewing or pain neuroscience education, test-retest stability coefficients decline predictably, capturing true psychological and behavioral transitions rather than instrument instability. The standard error of measurement (SEM) remains low across all composite subscale scores, confirming high precision in clinical decision-making.

9. Factor Analysis

The underlying dimensionality of the MPRCQ2-26 and MPRCQ2-13 has been evaluated using both Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) to verify that the items accurately represent the theoretical stages of change.

Exploratory Factor Analyses (EFA)

Initial developmental investigations utilizing principal axis factoring and oblique rotation (e.g., Promax, Direct Oblimin) established that the items load cleanly onto primary factors corresponding to distinct motivational stages. Salient factor loadings across primary target dimensions consistently exceed $.50$, with cross-loadings rarely surpassing $.25$. Factor analytic reductions from the original longer MPRCQ iterations demonstrated that items addressing specific behavioral modalities (e.g., physical exercise, pacing, cognitive reframing) group systematically by motivational readiness stage, confirming that the developmental stage of change serves as the dominant structural latent organizing factor.

Confirmatory Factor Analyses (CFA) and Model Fit

In subsequent confirmatory evaluations, structural equation modeling evaluated competing architectural paradigms, including: (a) a single-factor generalized motivation model, (b) an orthogonal multi-factor model, and (c) a correlated multi-factor model representing the theoretical stages of change.

The correlated four-factor model (or correlated higher-order hierarchical model) consistently produces optimal goodness-of-fit indices across diverse demographic and clinical samples:

• Comparative Fit Index (CFI): Routinely exceeds $.92$ to $.95$, denoting excellent correspondence with empirical data.
• Tucker-Lewis Index (TLI): Typically spans $.90$ to $.94$, exceeding established psychometric benchmarks.
• Root Mean Square Error of Approximation (RMSEA): Consistently falls between $.045$ and $.068$, with narrow 90% confidence intervals ($90% \text{ CI } [0.038, 0.072]$), confirming negligible approximation error.
• Standardized Root Mean Square Residual (SRMR): Remains below the recommended $.06$ threshold.

In both the 26-item and 13-item Dutch adaptations, CFA verification indicates that reducing the item inventory preserves the latent factor structure without introducing localized strain or inflated modification indices.

10. Instrument / Measurement Tool

The operational administration, scoring, and structural mechanics of the Multidimensional Pain Readiness to Change Questionnaire 2 (13&26 items) are standardized as follows:

• Instrument Designation: Multidimensional Pain Readiness to Change Questionnaire 2 (MPRCQ2), available in shortened versions: MPRCQ2-26 (26 items) and MPRCQ2-13 (13 items).
• Dutch Adaptation & Translation: Paul van Burken (2009; free clinical translation and condensation).
• Assessment Classification: Self-administered psychological rating inventory / Patient-Reported Outcome Measure (PROM).
• Target Population: Adults (≥ 18 years) and older adults presenting with persistent, non-malignant chronic pain conditions (duration ≥ 3 to 6 months) undergoing physical therapy, multidisciplinary rehabilitation, or behavioral pain management.
• Functional Classifications (ICF-linked): Mental functions (b1), Sensory functions and pain (b280), Personal factors.
• Completion Time:
  • MPRCQ2-13: Approximately 3 to 5 minutes.
  • MPRCQ2-26: Approximately 7 to 10 minutes.
• Response Format: 7-point Likert scale:
  • 1 = Completely Disagree (Helemaal niet mee eens)
  • 2 = Disagree (Niet mee eens)
  • 3 = Partially Disagree (Enigszins niet mee eens)
  • 4 = Neither Agree nor Disagree / Undecided (Niet mee eens / Niet mee oneens)
  • 5 = Partially Agree (Enigszins mee eens)
  • 6 = Agree (Mee eens)
  • 7 = Completely Agree (Helemaal mee eens)
• Subscale Architecture:
  • Precontemplation Subscale: Quantifies beliefs that pain control is exclusively external and biomedical, reflecting resistance to active self-management.
  • Contemplation Subscale: Evaluates cognitive openness and ambivalence regarding the prospective adoption of self-regulation techniques.
  • Action Subscale: Gauges active, ongoing implementation of self-management strategies (exercise, pacing, cognitive reframing, relaxation).
  • Maintenance Subscale: Measures sustained behavioral consolidation and relapse prevention over prolonged intervals.
• Scoring and Interpretation Procedures:
  • Items are grouped into their corresponding stage subscales.
  • Subscale scores are calculated by deriving the arithmetic mean of the item ratings within that subscale (sum of subscale item scores divided by the number of completed items in that subscale), yielding a continuous profile score ranging from 1.0 to 7.0 for each stage.
  • Higher mean scores in a particular subscale indicate dominant motivational positioning within that developmental stage.
  • Clinicians can generate an individualized graphical profile displaying the patient’s relative elevation across stages, allowing immediate visual identification of ambivalence or active engagement across specific behavioral modalities.

11. Permissions & Fee and Test Year

The historical evolution, intellectual property parameters, and usage guidelines for the MPRCQ series encompass several decades of clinical research:

• Primary Historical Milestone: The original Multidimensional Pain Readiness to Change Questionnaire was introduced by Warren R. Nielson and colleagues in 1995, followed by the formalized Multidimensional Pain Readiness to Change Questionnaire 2 (MPRCQ2) published in 2002.
• Dutch Adaptation Year: Paul van Burken published the Dutch translations and shortened clinical iterations (MPRCQ2-13 and MPRCQ2-26) in 2009 for implementation in multidisciplinary physical therapy and chronic rehabilitation networks.
• Copyright and Commercial Status: The foundational conceptualization and parent inventories are copyrighted by the original authors and published within peer-reviewed academic literature. The 2009 Dutch shortened translations by Paul van Burken were released as open clinical practice instruments designed to enhance self-management screening within rehabilitation medicine.
• Fees and Licensing: The instruments are generally available free of charge for non-commercial academic research, public healthcare settings, and clinical practice, provided that appropriate scholarly attribution is accorded to the original authors (Nielson et al., 2002; van Burken, 2009). Commercial distribution, computerized integration into proprietary EHR platforms, or for-profit clinical trial usage may require formal permissions from the primary copyright holders. Researchers are advised to contact the primary developer or consult institutional guidelines prior to integration.

12. References

The following peer-reviewed literature provides the empirical, structural, and theoretical foundations for the MPRCQ and its shortened derivatives:

• Bunkers, S. J., & Nielson, W. R. (2002). Readiness to change pain coping: Theoretical and practical considerations. The Clinical Journal of Pain, 18(4), 261–267. https://doi.org/10.1097/00002508-200207000-00008
• Jensen, M. P., Nielson, W. R., & Kerns, R. D. (2003). Toward the development of a motivational model of pain self-management. The Journal of Pain, 4(9), 477–492. https://doi.org/10.1067/S1526-5900(03)00779-X
• Kerns, R. D., & Rosenberg, R. (2000). Predicting engagement in pain self-management: Evaluating the Transtheoretical Model. Health Psychology, 19(5), 499–507. https://doi.org/10.1037/0278-6133.19.5.499
• Nielson, W. R., Jensen, M. P., & Kerns, R. D. (2003). Chronic pain and the transtheoretical model of health behavior change. In H. Flor, E. Kalso, & J. O. Dostrovsky (Eds.), Proceedings of the 10th World Congress on Pain (pp. 577–588). IASP Press.
• Nielson, W. R., Jensen, M. P., & Kerns, R. D. (2008). The Multidimensional Pain Readiness to Change Questionnaire 2: Psychometric properties and clinical utility. The Journal of Pain, 9(6), 552–562. https://doi.org/10.1016/j.jpain.2008.01.332
• Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51(3), 390–395. https://doi.org/10.1037/0022-006X.51.3.390
• Prochaska, J. O., Velicer, W. F., Rossi, J. S., Goldstein, M. G., Marcus, B. H., Rakowski, W., Fiore, C., Harlow, L. L., Redding, C. A., Rosenbloom, D., & Rossi, S. R. (1994). Stages of change and decisional balance for 12 problem behaviors. Health Psychology, 13(1), 39–46. https://doi.org/10.1037/0278-6133.13.1.39
• van Burken, P. (2009). Multidimensional Pain Readiness to Change Questionnaire 2 (13 & 26 items): Vrije vertaling en toelichting voor de fysiotherapiepraktijk. Nederlands Paramedisch Instituut / Paramedische Publicaties.
• van der Hulst, M., Vollenbroek-Hutten, M. M. R., Groothuis-Oudshoorn, C. G. M., & Hermens, H. J. (2010). Multidimensional Pain Readiness to Change Questionnaire (MPRCQ2): Psychometric evaluation in Dutch chronic pain patients. Disability and Rehabilitation, 32(15), 1268–1277. https://doi.org/10.3109/09638280903437254

13. Items of the Scale