The Pain Self-Efficacy Questionnaire, or PSEQ, is a 10-item patient-reported outcome measure used to assess how confident a client feels performing activities despite pain. Each item is scored from 0 to 6, giving a total score from 0 to 60. Higher scores indicate greater pain self-efficacy. The PSEQ can support education, activity planning and progress tracking, but it does not diagnose a condition, measure pain severity directly or clear someone for work, training or sport on its own.

Introduction

Pain can affect more than symptoms alone. It can influence confidence, activity choices, work participation, training behaviour, social activity and the ability to keep doing valued tasks.

The Pain Self-Efficacy Questionnaire, commonly called the PSEQ, is a patient-reported outcome measure that assesses how confident a person feels doing activities despite pain.

It is commonly used for:

• persistent pain
• chronic low back pain
• musculoskeletal pain
• rehabilitation progress tracking
• return-to-activity planning
• pain education support
• confidence monitoring
• biopsychosocial assessment
• activity and participation goal setting

The PSEQ is a 10-item questionnaire. Each item is scored from 0, meaning “not at all confident”, to 6, meaning “completely confident”. Total scores range from 0 to 60, where higher scores indicate stronger pain self-efficacy.  

Quick Summary

• Outcome measure: Pain Self-Efficacy Questionnaire
• Abbreviation: PSEQ
• Body region: Not region-specific
• Common use: Persistent pain and musculoskeletal pain contexts
• Type: Patient-reported confidence / self-efficacy measure
• Number of items: 10
• Item score: 0–6
• Total score range: 0–60
• Higher score means: Greater confidence functioning despite pain
• Lower score means: Lower confidence functioning despite pain
• Best used for: Baseline assessment, education planning, confidence monitoring and progress tracking
• Key limitation: PSEQ does not diagnose a condition, prove pain severity or determine clearance on its own

What Is the Pain Self-Efficacy Questionnaire?

The PSEQ is a questionnaire that measures confidence in performing activities while experiencing pain.

It asks the client to rate how confident they are that they can do different activities at present, despite pain.

The PSEQ includes:

• 10 items
• a 0–6 rating scale
• a total score from 0–60
• higher scores indicating greater pain self-efficacy

The official ePROVIDE listing identifies the PSEQ as an instrument developed by Nicholas and links it to the 2007 publication The Pain Self-Efficacy Questionnaire: Taking pain into account.  

The PSEQ is best understood as a confidence and self-efficacy measure, not a pain severity scale and not a diagnostic test.

Why It Is Used

The PSEQ is used because confidence can influence activity, participation and progress.

A client may have similar pain levels to another person but report very different confidence with:

• walking
• work tasks
• household activity
• exercise
• social activity
• goal pursuit
• pacing
• flare-up management
• returning to valued activities

The PSEQ can help professionals:

• understand confidence despite pain
• identify self-efficacy barriers
• support pain education
• guide graded activity planning
• monitor confidence over time
• support return-to-work or return-to-training conversations
• combine self-report findings with physical assessment
• improve documentation in Measurz

The PSEQ should support assessment reasoning and education. It should not be used to label the client or decide activity readiness on its own.

What It Measures

The PSEQ measures pain self-efficacy.

Pain self-efficacy refers to confidence in performing activities and managing life despite pain.

It may provide insight into:

• confidence with activity
• confidence with household tasks
• confidence with work tasks
• confidence with social participation
• confidence pursuing goals
• confidence coping with pain
• willingness to engage in valued activities
• perceived ability to function despite symptoms

It does not directly measure:

• pain intensity
• tissue damage
• structural pathology
• psychological diagnosis
• motivation
• effort
• strength
• range of motion
• readiness to return to sport
• readiness to return to work

Who It Is Useful For

The PSEQ may be useful for:

• exercise professionals
• rehabilitation practitioners
• workplace health professionals
• allied health support teams
• strength and conditioning coaches working with injured clients
• movement assessment professionals
• students learning pain-related outcome measures
• professionals using Measurz or MAT for structured progress tracking

It may be relevant for clients with:

• persistent musculoskeletal pain
• chronic low back pain
• recurrent pain episodes
• pain-related confidence loss
• reduced participation
• fear of flare-ups
• difficulty returning to normal activity
• difficulty progressing training
• difficulty maintaining work or social activities

A 2020 systematic review of pain-related self-efficacy measures in people with back pain found that the PSEQ and Chronic Pain Self-Efficacy Scale were the most commonly used instruments, although many studies lacked some aspects of reliability and validity evidence.  

When to Use This Outcome Measure

Use the PSEQ when you want to understand how confident the client feels functioning despite pain.

It may be useful at:

• initial assessment
• onboarding
• persistent pain review
• flare-up review
• pain education planning
• graded activity planning
• return-to-work planning
• return-to-training planning
• reassessment
• discharge or progress review

The PSEQ is most useful when repeated over time using the same version and scoring method.

When Not to Use or When to Be Cautious

Use caution when:

• the client cannot complete the questionnaire independently
• language or literacy affects responses
• the wrong language version is used
• the client interprets confidence questions as judgement
• the score is used to label the client
• the result is interpreted without physical and functional context
• the score is used as a pass/fail clearance decision

The PSEQ should not be used to:

• diagnose a pain condition
• diagnose anxiety or depression
• diagnose a psychological disorder
• confirm pain severity
• determine whether pain is “real”
• prove motivation or effort
• clear someone for work, training or sport
• replace a supportive conversation
• replace professional judgement

Equipment or Resources Required

• PSEQ questionnaire
• PSEQ scoring guide or calculator
• Measurz recording workflow
• Client-reported symptom and function notes
• Baseline and retest dates
• Optional related measures, such as:
  • Oswestry Disability Index
  • Roland-Morris Disability Questionnaire
  • Quebec Back Pain Disability Scale
  • Fear-Avoidance Beliefs Questionnaire
  • Tampa Scale for Kinesiophobia
  • Örebro Musculoskeletal Pain Screening Questionnaire
  • pain score
  • activity exposure notes
  • work participation notes

Administration Protocol / Practice

Setup

Explain the purpose of the questionnaire before the client completes it.

Example wording:

“This questionnaire helps us understand how confident you feel doing activities despite pain. It does not diagnose anything on its own, but it helps us plan education, activity progressions and progress tracking.”

Format

The PSEQ can be completed:

• on paper
• digitally
• independently
• verbally if assistance is needed
• before a session
• during reassessment
• as part of a Measurz workflow

Client Instructions

Ask the client to:

• read each statement carefully
• rate how confident they feel at present
• use the 0–6 scale
• answer every item where possible
• ask for clarification if they do not understand wording
• complete the same version at each retest

Completion Method

Record whether the PSEQ was completed:

• independently
• digitally
• on paper
• verbally
• with assistance

This supports repeatability and helps interpret change over time.

Assistance Rules

If assistance is needed:

• explain instructions without leading the answer
• avoid telling the client which score to choose
• avoid challenging responses during completion
• record that assistance was provided
• use the same assistance approach at retest where possible

Missing Item Handling

Do not guess missing responses.

For best practice:

• record missing items
• encourage completion of all 10 items
• avoid calculating a total score if the form is incomplete unless the scoring guide allows it
• interpret incomplete scores cautiously
• use the same version and scoring rules at retest

Scoring Process

The PSEQ includes 10 items.

Each item is scored from:

• 0: not at all confident
• 6: completely confident

The total score is calculated by adding all 10 items.

Score range:

• 0–60

Scoring direction:

• Higher score: greater pain self-efficacy
• Lower score: lower pain self-efficacy

Retesting Considerations

Retest at meaningful points, such as:

• baseline
• after pain education
• after graded activity progressions
• after a flare-up
• after increased training or work exposure
• during persistent pain monitoring
• discharge or progress review

For consistency, record:

• date
• current pain behaviour
• current activity exposure
• recent flare-ups
• current work or training exposure
• education or graded exposure stage
• current goals
• any major life, work or training changes

Safety Notes

The PSEQ is a self-report questionnaire, so it does not create physical testing risk.

However, very low or worsening scores may suggest the need to:

• explore confidence respectfully
• review education
• adjust graded activity planning
• support pacing and goal setting
• consider additional support where appropriate
• collaborate with other professionals when distress or participation restriction is significant

Scoring and Interpretation

The PSEQ produces a total score from 0 to 60.

Higher scores indicate greater pain self-efficacy.

Lower scores indicate lower confidence functioning despite pain.

Score Range

• 0: very low confidence across all items
• 60: very high confidence across all items

What a High Score May Suggest

A higher PSEQ score may suggest:

• greater confidence functioning despite pain
• stronger confidence with activity participation
• better perceived coping ability
• greater confidence pursuing goals
• fewer self-efficacy-related barriers to progression

What a Low Score May Suggest

A lower PSEQ score may suggest:

• lower confidence functioning despite pain
• greater concern about activity
• reduced perceived coping ability
• lower confidence with goals, work or daily tasks
• possible need for education, pacing or graded exposure support

What the Score Does Not Prove

A PSEQ score does not prove:

• diagnosis
• pain severity
• tissue damage
• psychological disorder
• motivation
• effort level
• readiness to return to work
• readiness to return to sport
• whether one intervention caused change

How to Explain the Result Safely

Example wording:

“Your PSEQ score suggests you are not yet feeling very confident doing some activities while pain is present. This does not mean anything is wrong with you psychologically. It gives us a useful starting point for education, graded activity and tracking confidence over time.”

What the Score May Mean in Different Client Populations

General Fitness Clients

For general fitness clients, the PSEQ may help identify whether pain-related confidence is affecting:

• gym participation
• walking
• lifting
• daily activity
• pacing
• confidence after flare-ups

Interpretation cautions:

• recent flare-ups may lower scores
• pain education can change confidence
• physical capacity should still be assessed

Sport and Performance Clients

For athletes, PSEQ may help identify broad confidence functioning despite pain, but it may not capture sport-specific readiness fully.

Interpretation should also include:

• sport-specific confidence
• return-to-training exposure
• workload history
• pain response to sport tasks
• psychological readiness measures where relevant
• sport-specific functional testing

A high PSEQ score should not be treated as return-to-sport clearance on its own.

Workplace Clients

For workplace contexts, PSEQ may help identify confidence with function despite pain.

Interpretation should also include:

• job demands
• work status
• modified duties
• work expectations
• confidence with work tasks
• functional capacity
• return-to-work planning

Older Adults

For older adults, PSEQ may help identify whether pain is affecting participation confidence.

Interpretation should consider:

• general health
• balance confidence
• comorbidities
• social support
• walking tolerance
• independent living goals

Youth Clients

The PSEQ is more commonly used in adults.

For youth clients, consider:

• comprehension
• school and sport context
• parent or guardian influence
• whether a youth-specific measure may be more suitable

Persistent Pain Clients

For persistent pain, PSEQ can help monitor whether confidence is changing alongside activity and participation.

Interpretation should also consider:

• pain self-efficacy
• fear-avoidance beliefs
• kinesiophobia
• mood and stress
• sleep
• work demands
• flare-up history
• participation goals

Meaningful Change, MCID, MDC and Responsiveness

Meaningful change helps determine whether a score change is likely to matter.

Key terms:

• MCID / MIC: the smallest change that may be meaningful to clients or professionals, depending on method used
• MDC: the amount of change likely needed to exceed measurement error
• SEM: estimated measurement error around a score
• Responsiveness: ability of the questionnaire to detect change over time

PSEQ Meaningful Change Evidence

A 2016 study in people with chronic low back pain examined responsiveness and minimal important change for the PSEQ, PSEQ-2 and PSEQ-4. The study states that the full PSEQ is a valid and reliable patient-reported instrument for assessing pain self-efficacy in chronic low back pain and that shorter versions had satisfactory measurement properties in mixed chronic pain populations.  

Meaningful change values should be matched to:

• full PSEQ versus short version
• chronic low back pain versus other pain presentations
• language version
• baseline score
• intervention or education context
• follow-up timeframe

Practical Interpretation

When interpreting PSEQ change:

• compare the total score with baseline
• check whether confidence changes match activity exposure
• compare with pain, disability and function measures
• look for changes in behaviour and participation
• consider recent flare-ups or setbacks
• avoid over-interpreting very small changes

When Values Are Uncertain

Reported meaningful change values may vary by:

• persistent pain condition
• low back pain versus broader musculoskeletal pain
• baseline confidence
• education approach
• follow-up timeframe
• language version
• scoring version

When no matching MCID, MDC or SEM exists, interpretation should rely more heavily on:

• baseline comparison
• repeated measurement
• client conversation
• activity exposure
• work participation
• disability scores
• professional judgement

Normative Data, Reference Values or Comparative Data

Universal PSEQ norms are limited and should be used cautiously.

The PSEQ is best interpreted through:

• baseline comparison
• score change over time
• client goals
• current activity exposure
• pain and disability measures
• confidence-related conversation

Practical guidance:

• Lower scores suggest lower pain self-efficacy.
• Higher scores suggest greater pain self-efficacy.
• A high score does not guarantee readiness for sport, work or training.
• A low score should prompt support and education, not judgement.
• Repeated scores are often more useful than one isolated result.

Comparison should consider:

• pain duration
• pain condition
• activity exposure
• work status
• recent flare-ups
• previous pain education
• language version
• cultural context
• disability level
• support systems

Reliability and Validity

The PSEQ has post-2000 evidence supporting its use, especially in persistent pain and musculoskeletal pain contexts.

The official ePROVIDE listing identifies the 2007 Nicholas paper as the primary published source for the PSEQ.  

A 2021 systematic review of PSEQ measurement properties in musculoskeletal disorders reported that the PSEQ is one of the most frequently used patient-reported measures for pain self-efficacy and aimed to identify, appraise and synthesise its psychometric properties.  

A 2020 systematic review of pain-related self-efficacy measures in people with back pain reported that PSEQ and the Chronic Pain Self-Efficacy Scale were the most commonly used instruments, but many studies lacked some aspects of reliability and validity evidence.  

Reliability and validity are stronger when:

• the correct version is used
• the correct language version is used
• all 10 items are completed
• missing items are handled consistently
• the same scoring method is repeated
• results are interpreted in context
• PSEQ is paired with disability, function and pain measures

Interpret cautiously when:

• multiple items are missing
• the client has difficulty understanding statements
• the score is used to label the client
• the score is used as a stand-alone return-to-activity decision
• a shortened version is used without noting its specific scoring and evidence
• the language version has limited validation evidence

Common Errors and Limitations

Common errors include:

• treating PSEQ as a diagnosis
• using the score to label the client
• interpreting low confidence as poor motivation
• using PSEQ as return-to-work clearance
• using PSEQ as return-to-sport clearance
• not recording missing items
• using different versions across retests
• over-interpreting one score
• failing to discuss results respectfully
• failing to pair the score with function and physical assessment

Limitations include:

• self-report may be influenced by recent pain, stress or flare-ups
• high scores do not prove readiness
• low scores do not prove poor effort
• universal norms are limited
• meaningful change evidence varies by population
• it does not capture sport-specific readiness
• it should be paired with physical, functional and psychosocial assessment

Practical Applications

The PSEQ may help professionals:

• document baseline confidence despite pain
• identify self-efficacy-related barriers
• guide pain education
• support graded activity planning
• support pacing discussions
• monitor confidence change over time
• support return-to-work or return-to-training conversations
• improve client-centred communication
• strengthen Measurz reports

For fitness clients, it can help show whether pain-related confidence is affecting training progression.

For workplace clients, it can help identify confidence around work tasks and activity participation.

For persistent pain clients, it can help monitor whether confidence changes alongside pain, disability and exposure.

For Measurz users, PSEQ is most useful when combined with:

• Oswestry Disability Index
• Roland-Morris Disability Questionnaire
• Quebec Back Pain Disability Scale
• Fear-Avoidance Beliefs Questionnaire
• Tampa Scale for Kinesiophobia
• Örebro Musculoskeletal Pain Screening Questionnaire
• pain score
• activity exposure notes
• work participation notes

How to Record This in Measurz

Record:

• outcome measure name: Pain Self-Efficacy Questionnaire / PSEQ
• version used: 10-item, PSEQ-2, PSEQ-4 or other
• date completed
• completion method: paper, digital, interview or assisted
• language/version used
• condition or presentation being tracked
• total score
• score range:
  • full PSEQ: 0–60
• direction of scoring: higher score indicates greater pain self-efficacy
• missing items, if any
• assistance provided, if any
• current pain score, if relevant
• current disability score, if relevant
• current activity exposure
• current work or training exposure
• key low-confidence themes
• confidence or participation goals
• education or graded activity notes
• baseline comparison
• MCID/MIC/MDC comparison where supported
• related physical assessment findings
• interpretation notes
• retest date
• referral or collaboration notes where appropriate

Record whether the main concern appears to be:

• low activity confidence
• low work confidence
• low social or participation confidence
• flare-up confidence issue
• mixed self-efficacy limitation
• unclear due to incomplete responses

This improves:

• repeatability
• communication
• client education
• assessment reasoning
• monitoring over time
• team consistency
• reporting quality

Related Outcome Measures / Internal Links

• Fear-Avoidance Beliefs Questionnaire / FABQ
• Tampa Scale for Kinesiophobia / TSK
• Örebro Musculoskeletal Pain Screening Questionnaire
• Oswestry Disability Questionnaire
• Quebec Back Pain Disability Scale
• Roland-Morris Lower Back Pain Disability Questionnaire
• Spine Function Index-10
• Neck Disability Index
• Lower Extremity Functional Scale / LEFS

FAQs

What does the PSEQ measure?

The PSEQ measures how confident a client feels performing activities despite pain.

How many items are in the PSEQ?

The full PSEQ has 10 items.

How is the PSEQ scored?

Each item is scored from 0 to 6. The total score ranges from 0 to 60.

Does a higher PSEQ score mean better pain self-efficacy?

Yes. Higher scores indicate greater confidence functioning despite pain.

Does PSEQ diagnose a pain condition?

No. PSEQ measures pain self-efficacy. It does not diagnose the cause of pain, pain severity or a psychological condition.

Can PSEQ be used for chronic pain?

Yes. PSEQ is commonly used in persistent and chronic pain contexts, including chronic low back pain and musculoskeletal pain populations.  

What is a meaningful change in PSEQ?

Meaningful change varies by population and version. Research has examined responsiveness and minimal important change in chronic low back pain, but values should be matched to the specific client group and PSEQ version.  

Can PSEQ be used for return-to-work or sport decisions?

It can support return-to-work or return-to-activity reasoning, but it should not be the only decision measure. It should be combined with function, activity exposure, pain behaviour, physical testing and professional judgement.

Key Takeaways

• The PSEQ is a 10-item pain self-efficacy questionnaire.
• Each item is scored from 0 to 6.
• Total scores range from 0 to 60.
• Higher scores indicate greater confidence functioning despite pain.
• PSEQ does not diagnose pain cause, psychological status or activity readiness.
• It is useful for education planning, graded activity and progress tracking.
• Meaningful change values should be matched to the client population and version.
• Measurz should record version, total score, completion method, missing items, activity exposure, confidence themes, baseline comparison and related physical findings.

References

Dubé, M.-O., Langevin, P., Roy, J.-S., & Desmeules, F. (2021). Measurement properties of the Pain Self-Efficacy Questionnaire in populations with musculoskeletal disorders: A systematic review. Pain Practice. https://doi.org/10.1111/papr.13049

Chiarotto, A., Vanti, C., Cedraschi, C., Ferrari, S., de Lima e Sá Resende, F., Ostelo, R. W. J. G., Pillastrini, P., & Terwee, C. B. (2016). Responsiveness and minimal important change of the Pain Self-Efficacy Questionnaire and short forms in patients with chronic low back pain. The Journal of Pain, 17(6), 707–718. https://doi.org/10.1016/j.jpain.2016.02.012

Di Pietro, F., Catley, M. J., McAuley, J. H., Parkitny, L., Maher, C. G., Costa, L. O. P., & Macedo, L. G. (2014). Rasch analysis supports the use of the Pain Self-Efficacy Questionnaire. Physical Therapy, 94(1), 91–100. https://doi.org/10.2522/ptj.20130217

Nicholas, M. K. (2007). The Pain Self-Efficacy Questionnaire: Taking pain into account. European Journal of Pain, 11(2), 153–163. https://doi.org/10.1016/j.ejpain.2005.12.008

Shirley Ryan AbilityLab. (2024). Pain Self-Efficacy Questionnaire. RehabMeasures Database. https://www.sralab.org/rehabilitation-measures/pain-self-efficacy-questionnaire

Turner, J. A., Holtzman, S., & Mancl, L. (2007). Mediators, moderators, and predictors of therapeutic change in cognitive-behavioral therapy for chronic pain. Pain, 127(3), 276–286. https://doi.org/10.1016/j.pain.2006.09.005