e100 S. Coaccioli et al.

Validation of an original questionnaire for patients with

psoriatic arthritis: The Psoriatic Arthritis Impact Prole (PAIP)
S. Coaccioli, A.A. Bruno, G. Celi, M.E. Crapa, V.R. Ferri, F. Masia, M. Papini
Internal Medicine and Rheumatology, and Dermatology Unit. Perugia University School of Medicine, Santa Maria General
Hospital, Terni, Italy
Original article
Clin Ter 2014; 165 (2):e100-108. doi: 10.7471/CT.2014.1691
Correspondence: Prof. Stefano Coaccioli, MD, PhD. Chief, Internal Medicine and Rheumatology, Perugia University School of Medicine, Santa
Maria General Hospital, via T. di Joannuccio 1, 05100 Terni, Italy. E-mail: stefano.coaccioli@unipg.it
Copyright Societ Editrice Universo (SEU)
ISSN 1972-6007
Introduction
Psoriatic Arthritis (PsA) and Psoriasis (Ps) are associated
to multiple health problems and considerably interfere with
the quality of Life (QoL). These problems include physical
symptoms linked both to the articular and cutaneous disea-
ses, difculties in performing daily activities and social in-
teractions, along with work problems. A study performed by
the National Survey of Functional Health Status has revealed
that patients with Ps refer of a worsened QoL compared to
patients with arthritis, cancer, chronic lung disease, hyper-
Abstract
Background and Aims. There is a wide evidence that Psoriatic
Arthritis (PsA) as well as Psoriasis (Ps) lead to signicant health pro-
blems and interfere with the patient quality of life (QoL). Even though
a validated questionnaire for Ps is available, no questionnaire for PsA
is currently present in literature. The aim of our work has been to con-
rm the efcacy of our original questionnaire as well as to validate it,
through the comparison with other existing recognised and accepted
questionnaires, such as MOF-SF36, HAQ, McGill Pain Questionnaire,
and Zeung Self-Rating Depression and Anxiety Scales.
Materials and Methods. We have realized a questionnaire for
PsA (Psoriatic Arthritis Impact Questionnaire, PAIP), in terms of
psychological and rheumatological evaluation, QoL, social and eco-
nomic assets.
Results. The statistical comparisons between PAIP and the accepted
questionnaires (see above) conrm that PAIP is widely validated and
represents a useful tool suitable for clinical evaluation and management
of patients with PsA.
Conclusions. The indexes of the correlation among the different
parts of PAIP and the other questionnaires have shown positive correla-
tions. Moreover, PAIP presents a dedicated unit for the economical and
therapeutic parameters, The short time for compilation (15 minutes), the
easy of comprehension of the questions, and above all the validation
of PAIP, make our questionnaire a useful tool, suitable for the clinical
management of the patients with PsA. Clin Ter 2014; 165(2):e100-108.
doi: 10.7417/CT.2014.1691
Key words: psoriasis, psoriatic arthritis, pain, quality of life, que-
stionnaire, validation
tension, myocardial infarction, diabetes and depression (1).
Qualitative studies evaluating the conditions of life of the
patients affected by Ps, have targeted that the most recurrent
issue is the feeling of discrimination (2), then the loss of
self-esteem, failure of the interpersonal relations, anxiety
and depression (3). Suicidal death happens, in fact, in the
5.5% of the cases in the patients with Ps, against the 0.12%
of the population in general (3). According to many studies,
the severity of Ps (4) is associated to a worsened status of
the mental health, both in the patients with Ps and in the
patients with PsA (5).
Until a few years ago, PsA was considered as a less
severe rheumatic pathology compared to the other inam-
matory arthritis, as common belief was that this would
affect a lower number of joints, and that only in rare ca-
ses this disease would have a destructive growth. On the
contrary, it is now clear that PsA can be as destructive for
joints, generating disability and worsening the QoL. The
term impact, as meant as for weighting the disease, is
relatively bad dened and it has been, recently, suggested
that personal impact in this approach is of fundamental im-
portance in order to understand the patients point of view
(6), at the point that this would suggest that it is necessary
to substitute the actual outcomes referred to the patient with
some totally new parameters that would better describe the
individual perception of the patient himself, considering that
the severity of his condition has to be evaluated also in the
light of a social perspective.
The international Classication of Functioning Disability
and Health (ICF) has recently given a useful framework to
evaluate the overall impact of Ps (7). The ICF holds that
the impact of this disease can be seen as the expression of
the indispositions and its consequently malfunctioning of
the body. As for a body to operate correctly, in fact, this is
seen to be working on three levels: the organic level (bodys
structures or physiological functions, for instance the range
of motion, i.e., articular), the personal level (limitation of
activities; as getting dressed for example), and the social
level (restrictions in participating to the activities of the com-
munity; as going to work, for example). In addition, the ICF
model claims that the functional expression of the disease is
inuenced not only by the disease in itself, but also by some
e101 Questionnaire for Psoriatic Arthritis
personal dynamics, as could be the age range, the genre and
also some psychological features. It can also be inuenced by
the environmental setting, including the possibility, or not, to
easily access the treatments and the social responses to the
individual suffering. This model seems to offer signicant
help to evaluate as the individual is affected by PsA (7).
Although, many qualitative studies have conrmed that PsA
is associated to many daily challenges, it does not currently
exist a standard questionnaire able to cover every area of
problems. At the moment we do have only questionnaires
for each separated area, or different questionnaires for the
same area of issues to be explored.
The purposes of our work are substantially two: 1) give
an overall framework of the QoL of the patients with PsA
and Ps through the use of standard questionnaires validated
and normally used in the clinical trials; 2) conrm the ef-
cacy of an original questionnaire (PAIP, Psoriatic Arthritis
Impact Prole) elaborated by us with the intent of validate
it, through the use along with the other existing recognised
questionnaires. We aim our questionnaire to become a uni-
fying tool to assess the overall experience and perceptions
of the patients with PsA and Ps (8), especially because it
has been expressly formulated to discriminate what value
the patient bestows to the PsA and to the Ps.
Materials and Methods
The sample of our study was constituted by 123 patients
(of an average age of 49.63 years, ranging 22-82, 58 males,
65 females). All the patients were affected by Ps (medium
duration, 16.5 years). More than a third of the patients (82)
presented also a diagnosis of PsA, given in the majority of
the cases after (39) or simultaneously (31) with the diagno-
sis of Ps; only in 12 cases (10%) PsA appeared before the
onset of Ps. To evaluate the entity of cutaneous involvement,
all the patients were assessed with PASI (Psoriasis Area
Severity Index, 9). Dermatological manifestations resulted
to be low in 71 patients, moderate in 22 and severe in 25.
All the patients have been enrolled, after they have signed
an informed consent agreement, by the Internal Medicine
and Rheumatology, and Dermatology Unit of the Perugia
University School of Medicine in the Santa Maria General
Hospital. The parameter that has been used for the patients
to be admitted was that they had already to be clinically dia-
gnosed as affected by PsA and/or by Ps by a rheumatologist,
a dermatologist and by a general practitioner. Other than the
PASI, for all the patients we have used other questionnaires
aimed to evaluate the impact of the disease on QoL (PAIP,
MOS SF-32, MPQ, S-HAQ, ZSAS e ZSDS). Nevertheless,
our research is largely based on the Psoriasis Arthritis Impact
Prole (PAIP) (8). We have divided the PAIP in ve parts:
a general part and a share of four special parts. In the
general part (Table 1) are addressed: the patients personal
details, the duration of PsA and Ps, possible hospitalizations
for both pathologies, the undergone therapies, an evaluation
of the percentage of the extension of the cutaneous disease
(0 = 0-5%, 1 = 5-10%, 2 = 10-30%, 3 = >30%) and its loca-
lization, an evaluation of the pain as perceived by the patient
in the VAS pain scale (0: 0-10%, 1: 10-30%, 2: 3070%, 3:
>70%) and its localization. The special parts are composed
by multiple answers tests, and the possibility to give to each
answer a value between 0 and 3, depending on severity.
To some of the questions, it is possible to answer giving a
specic connection to PsA or Ps.
Special Part I (Table 2) gives a psychological evaluation
of the patient and is based on 6 items, with a maximum
average of 27 points (21 for Ps).
Special Part II (Table 3) gives a social dimension asses-
sment of the patient and it is composed by 4 items, with a
maximum average of 18 points (12 for Ps).
Special Part III (Table 4) gives a rheumatologic evalua-
tion of the patient exploring the possible disabilities and
the inability to the normal daily activities, and is based on
7 items with a maximum average of 21.
Special Part IV (Table 5) gives information on the socio-
economic and therapeutic aspects, including the range value
of the annual expenses afforded by the patient, except for
the free services given by the National Health Care Servi-
ce, and is based on 6 items with a maximum average of 18
points. The total score of PAIP is given by the sum of the
points given in the 4 special parts and can have an overall
result ranging between 0 and 84 for the patients with PsA,
and between 0 and 52 for the patients with Ps. The PAIP is
available also in the English version and it takes about 15
minutes to be completed.
For the clinical evaluation of Ps severity, we have used
the PASI (9). In order to evaluate the impact of QoL and to
validate our questionnaire, the PAIP has been assessed in
comparison of 4 validated tests, largely recognised and used
in the clinical practice and statistical analyses: the Medical
Outcome Scale Short Form 36 items (MOS SF-36) (10, 11),
the McGill Pain Questionnaire (MPQ) (12, 13), the Zeung
Self-Rating Depression Scale (ZSDS) (14) and the Zeung
Self-Rating Anxiety Scale (ZSAS) (15). Patients affected by
PsA have been assessed also with the Health Assessment
Questionnaire (HAQ) (16,17), modied to evaluate spon-
dyloarthritis (18).
Results
The data sprung from our study have been calculated
using the Spearman coefcient of correlation formula and
elaborating the data with the Statistical Package for Social
Science (SPSS

Statistics di IBM v21, 2012). Moreover,

some correlations have been examined between the severity
of Ps and some factors like age, genre and duration of the
disease. The PASI score has not resulted linked with any
factor as age or genre; rather it seems to be related with the
duration of Ps (Table 6).
Some other correspondences have been observed to
look for links among the areas explored through the diffe-
rent questionnaires used, and the variables of age, genre,
duration of disease and severity of Ps. For the outcome of
the patient, valued with the MOS SF-36, we have observed
that physical activity (PA) is linked with age, while social
activities (SA) are mostly related with the severity of Ps
(PASI). Also, vitality (VT) could be associated with the
PASI score (Table 7).
Putting pain into the picture (test MPQ), we have seen
some correlations with the severity of Ps (PASI), both in the
e102 S. Coaccioli et al.
total score and in the different classes of MPQ (Table 8).
The subjective evaluation of pain has resulted to be, on the
contrary, independent from the parameters like the age and
the duration of disease (Table 8).
The level of disability has been evaluated with the HAQ
questionnaire. Results show that disability is independent
from the age factor, but is linked to the duration of PsA
(Table 9).
Finally, we have observed the distribution of the anxiety
and depression symptomatology (respectively through the
ZSAS and the ZSDS questionnaires) without nding any
signicant correlation with the variables taken into consi-
deration (Table 10).
To be able to evaluate the efcacy of PAIP as the lonely
and unique tool for the overall evaluation of the patient
conditions, we have examined the distribution of the values
of the sample survey. Later, we evaluated the convergent
validity through the determination of the Spearman Index
between the PAIP and the correlated scales. The psycholo-
gical dimension (PAIP I) resulted to be signicantly corre-
lated with the duration of PsA; the social Impact (PAIP II)
seems to be, instead, mostly inuenced by the severity of
Ps (PASI). Finally, the rheumatologic evaluation (PAIP III)
has resulted to be strictly correlated with the duration of Ps
(Table 11). Among the questionnaires we have used, we
have taken into consideration the MOS SF-2, as one of the
most and universally used among the evaluation tools. As we
expected, our work has shown some strict correlations with
the subscales that are conceptually alike to the two tests. The
rst section of PAIP has been confronted with the subscales
e103 Questionnaire for Psoriatic Arthritis
ER (emotional role and status) and MH (mental health); the
second section with the subscales RP (Role and Physical
HEALTH) and SA (social activities); the third section has
been confronted with PA (Physical activity), PP (physical
pain) and VT (vitality). Also, the nal score of the two tests
resulted to be highly correlated, both in the sample survey
and in the group of patients affected only by arthritis (Table
12 and Table 13). In the subjective evaluation of pain (MPQ),
we have found signicant correlations both with the total
value of PAIP and with the different subscales (Table 14).
For disability level, we have found strong correlations
with the third dimension of PAIP (rheumatologic evaluation)
and with the total score of the test (Table 15). Finally, the
tests ZSDS and ZSAS confronted with the 2 rst sections of
the PAIP regarding the psychological and social evaluation
of the patient with Ps, have shown the positive correlations
presented in Table 16.
Discussion
From the analysis of the results shown in our study, some
considerations can be drawn as follows: the severity of Ps
(score PASI) is not linked with the parameter of age nor with
the gender, but appears to be linked with the duration of the
disease, bringing out the evolutive character of Ps; social
activities (subclass AS of MOS SF-36) result mostly com-
promised in the patients with a sever cutaneous involvement;
regarding the feeling of stigmatization frequently shown
in the patients with Ps, it does not surprise that the severity
e104 S. Coaccioli et al.
of skin damages is the factor properly and mostly correlated
with the social participation; the subjective evaluation of pain
(score MPQ) results more severe in the patients with PASI
high scores. This outcome can be justied from the fact that,
in our sample survey, patients with PsA have obtained an
average of higher PASI scores compared to the patients with
Ps (12.9 against 10.4 of the patients with PsA). Disability
(questionnaire HAQ) has resulted strongly correlated with
the duration of the disease. Also, this result is justied by the
development and disposition of the disease, which in some
cases can have a progressive elapse towards disability. The
presence of psychological symptoms, as anxiety and depres-
sion (score ZSAS and ZSDS) is resulted to be independent
from the age, from the severity of the cutaneous involvement
and from the duration of the pathology. In this eld, the
individual parameters are most probably to play a role of
primary importance, as long as with the psychological and
the distinctive individual responses of the patient, similarly
with the different ways of patients to deal with the disease
and the familiar and social environment they are involved
with. Regarding the dimensions evaluated with the PAIP, we
have observed that the psychological dimension (PAIP I)
appears to be independent from the age, duration of disease
(Ps) and from the severity of the cutaneous involvement,
accordingly with what we have observed through the use of
the questionnaires ZSAS and ZSDS; considering only the
patients with PsA, the psychological discomfort is resulted to
be linked instead with the duration of the disease; the social
dimension (PAIP II) seems to be directly related with the
severity of the cutaneous manifestations, accordingly with
e105 Questionnaire for Psoriatic Arthritis
what we have observed through the subscale AS of MOS
SF-36; accordingly with what we have observed through the
use of the questionnaire HAQ, the rheumatologic dimension
(PAIP III) results to be strongly correlated to the duration
of PsA. About the ratio between the PAIP dimensions and
the correlated scales with other evaluation tools, our study
has conrmed that there are strict correlations with all the
scales conceptually alike. Total score of PAIP is strictly
correlated with the total score of MOS SF-36: the rst part
of PAIP, i.e. the one that explores the psychological aspect
of the disease, is resulted to be correlated with the MOS
SF-36 role and emotional status (RE) and mental health
(MH); the second part of PAIP, exploring the social impact of
the disease, is correlated to the scales
role and physical health (RP) and
social activities (SA); third part of
PAIP, strictly exploring the rheuma-
tologic area, results strictly correlated
with the scales physical as well as
the scores of its single parts, result to
be correlated with the score of MPQ.
This result conrms that pain, and in
particular how patients feel and ex-
perience pain, does give an inuence
on all the areas of the patients life,
starting from the psychological and
social dimension, to the economi-
cal dimension. Especially relevant
have been resulted the correlations
among the emotional aspect of
pain (PRI-A) and the psychological
dimension (PAIP I) and the total score
of MPQ, the economical dimension
(PAIP V). In the patients with PsA,
the rheumatologic dimension (PAIP
III), has resulted to be strictly correla-
ted with the severity of the disability,
explored with HAQ and S-HAQ.
Finally, the psychological (PAIP I)
and the social (PAIP II) dimensions
have resulted to be correlated with
the level of anxiety and depression
explored respectively with ZSAS
and ZSDS. As conclusive conside-
rations, we can afrm that PAIP has
conrmed to be for us a valid tool
for the evaluation of the patients with
PsA and Ps. The PAIP questionnaire,
both in its entireness and in its single
parts, has shown a distribution of the
sample studied substantially similar
to the one in the other test, all widely
validated by the literature, as well as
by the clinical practice. Moreover, the
indexes of the correlation among the
different parts of PAIP and the scales
conceptually alike of the other que-
stionnaires have shown their positive
correlation. Moreover, PAIP presents
a dedicated unit for the economical
and therapeutic parameters, an area scarcely explored by
the other available questionnaires, nonetheless extremely
important to be evaluated, both on the practical-clinical and
statistical-epidemiological level. To our opinion, the time
for compilation (15 minutes), the easy of comprehension
of the questions, and above all the validation of PAIP,
make our questionnaire a useful tool, suitable for the clinical
management of the patients with PsA.
Aknowledgments
The Authors would like to thank Ms. Marta Di Felice
for her excellent secretarial assistance in the revision of the
e106 S. Coaccioli et al.
Table 6. Correlation between PASI, age, gender, and duration of
Psoriasis (Ps).
PASI
Age Rho = -0.012
Gender Rho = 0.251
Duration of Ps Rho = 0.503 *
*signicant correlation at 0.01
Table 8. Correlation between MPQ scales (S, sensorial; A, affective; V, valutative), PASI, age, and duration of Psoriasis (Ps).
PRI-S PRI-A PRI-V PRI-total
PASI Rho = 0.551 ** Rho = 0.386 * Rho = 0.433 ** Rho = 0.543
Age Rho = 0.041 Rho = -0.004 Rho = -0.118 Rho = -0.007
Duration of Ps Rho = -0.232 Rho = 0.160 Rho = -0.277 Rho = -0.287
* signicant correlation at 0.05; ** signicant correlation at 0.01
Table 7. Correlation between subscores of MOS SF-32, age, PASI,
and duration of Psoriasis (Ps).
MOS-AF MOS-VT MOS-AS
Age Rho = 0.371 * Rho = 0.032 Rho = 0.034
PASI Rho = 0.112 Rho = 0.437 ** Rho = 0.437 **
Duration of Ps Rho = 0.017 Rho = 0.118 Rho = 0.273
* signicant correlation at 0.05; ** signicant correlation at 0.01
e107 Questionnaire for Psoriatic Arthritis
Table 9. Correlation between HAQ, age, and duration of Psoriatic
Arthritis (PsA).
HAQ S-HAQ
Age Rho = 0.253 Rho = 0.221
Duration of PsA Rho = 0.634 * Rho = 0.615 *
* Signicant correlation at 0.01
Table 11. Correlation between PAIP and age, PASI, duration of Psoriasis (Ps), duration of Psoriatic Arthritis (PsA).
PAIP-I PAIP-II PAIP-III PAIP-IV
Age Rho = 0.161 Rho = -0.040 Rho = 0.258 Rho = 0.012
PASI Rho = 0.270 Rho = 0.461 * Rho = 0.138 Rho = 0.303
Duration of Ps Rho = 0.209 Rho = 0.301 Rho = 0.025 Rho = 0.288
Duration of PsA Rho = 0.496 * Rho= 0.153 Rho = 0.679 * Rho = 0.024
* Signicant correlation at 0.01
Table 12. Correlation between PAIP and subscores of MOF SF-32.
PAIP I PAIP II PAIP III PAIP IV PAIP total
MOS AF - - Rho = 0.802 * - -
MOS DF - - Rho = 0.553 * - -
MOS RF - Rho = 0.520 * - - -
MOS VT - - Rho = 0.528 * - -
MOS SM Rho = 0.602 * - - - -
MOS AS - Rho = 0.830 * - - -
MOS RE Rho = 0.573 * - - - -
MOS total - - - - Rho= 0.843 *

* Signicant correlation at 0.01
Table 13. Correlation between PAIP and subscores of MOF SF-32 in patients with Psoriatic Arthritis (PsA)
PAIP I PAIP II PAIP III PAIP IV PAIP total
MOS AF - - Rho = 0.773 ** - -
MOS DF - - Rho = 0.568 ** - -
MOS RF - Rho = 0.496 * - - -
MOS VT - - Rho = 0.531 ** - -
MOS SM Rho = 0.424 * - - - -
MOS AS - Rho = 0.816 * - - -
MOS RE Rho = 0.487 * - - - -
MOS total - - - - Rho = 0.818 **
* Signicant correlation at 0.05; ** signicant correlation at 0.01
Table 14. Correlation between PAIP and subscores of MPQ.
PAIP I PAIP II PAIP III PAIP IV PAIP total
PRI S Rho = 0.583 * Rho = 0.601 * Rho = 0.506 * Rho = 0.520 * Rho = 0.690 *
PRI A Rho = 0.636 * Rho = 0.517 * Rho = 0.593 * Rho = 0.535 * Rho = 0.732 *
PRI V Rho = 0.567 * Rho = 0.531 * Rho = 0.461 * Rho = 0.546 * Rho = 0.632 *
PRI total Rho = 0.624 * Rho = 0.618 * Rho = 0.554 * Rho = 0.562 * Rho = 0.737 *
* Signicant correlation at 0.01
Table 10. Correlation between ZSAS and ZSDS, and age, duration
of Psoriasis (Ps), duration of Psoriatic Arthritis (PsA), PASI.
ZSAS ZSDS
Age Rho = -0.062 Rho = -0.046
Duration of Ps Rho = 0.084 Rho = 0.084
Duration of PsA Rho = 0.130 Rho = 0.181
PASI Rho = 0.249 Rho = 0.291
e108 S. Coaccioli et al.
manuscript. This study has been realized under the auspices
of the Italian Association for the Study of Pain (AISD), the
Paolo Procacci Foundation (PPF), and the Lions Interna-
tional Association (108L District of I.T.A.L.Y) of behalf
of Club of San Gemini-Terni dei Naharti.
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Table 15. Correlation between PAIP and HAQ, and S-HAQ.
PAIP III PAIP total
HAQ Rho = 0.979 * Rho = 0.689 *
S-HAQ Rho = 0.940 * Rho = 0.620 *
* Signicant correlation at 0.01
Table 16. Correlation between PAIP and ZSAS e ZSDS.
PAIP I PAIP II
ZSDS Rho = 0.593 * Rho = 0.495 *
ZSAS Rho = 0.574 * Rho = 0.597 *
* Signicant correlation at 0.01