The Fear Avoidance Model Disentangled: Improving the Clinical Utility of the Fear Avoidance Model

Back pain beliefs are related to the impact of low back pain in baby boomers in the Busselton Healthy Aging Study

BACKGROUND

Back pain beliefs (BPBs) are an important modifiable factor related to disability associated with low back pain (LBP). Back pain beliefs have not been characterized in baby boomers, a group at risk for decreased activity levels and reduced productivity.

OBJECTIVE

The aims of this study were: (1) to identify factors related to BPBs and (2) to evaluate the association between LBP disability and beliefs.

DESIGN

A cross-sectional survey of community-dwelling baby boomers (born 1946-1964) was conducted.

METHODS

Nine hundred fifty-eight baby boomers (mean age=56.2 years) participating in the Busselton Healthy Aging Study provided their history of LBP, BPBs, LBP behaviors related to care seeking (taking medication, seeking professional help) and activity modification (missing work, interference with normal activities, interference with recreational activities), LBP-related disability, and additional covariates with known associations with BPBs. Regression analyses were used to: (1) identify factors associated with more positive beliefs and (2) test the association between more positive BPBs and lower LBP disability, independent of other correlates of BPBs.

RESULTS

More positive BPBs were associated with younger age, better mental well-being, and higher income, whereas more negative BPBs were associated with receiving sickness or disability benefits and the experience of LBP in the previous month. In participants who reported experiencing LBP within the previous month, more positive BPBs were associated with lower disability scale scores and a decreased probability of interference with usual activities, independent of pain intensity, age, mental well-being, income, and employment status.

LIMITATIONS

Cross-sectional analysis limits assessment of causality.

CONCLUSIONS

Poorer BPBs were associated with greater disability. Characterization of the relationships between BPBs and LBP-associated behaviors and disability in baby boomers can assist in developing interventions to improve activity participation and productivity, potentially reducing the burden of LBP in this age group.

Spanish Version of the Pain Vigilance and Awareness Questionnaire: Psychometric Properties in a Sample of Women with Fibromyalgia

Excessive attention to pain is a common psychological characteristic among people who suffer from chronic pain. The Pain Vigilance and Awareness Questionnaire (PVAQ) is an internationally accepted tool to assess this feature, although there is no validated version of this measure for Spanish people with fibromyalgia. Since this pain syndrome mainly affects women, the aim of this study was to determine the psychometric properties of the PVAQ in Spanish women with fibromyalgia. A group of 242 women diagnosed with fibromyalgia aged between 20 and 66 years participated in the study. The goodness of fit of several structures of the PVAQ reported in previous studies was compared via confirmatory factor analysis. A two-factor solution (active vigilance and passive awareness) of the 9-item shortened version (PVAQ-9) was identified as the most appropriate (RMSEA = .08, NNFI = .96, CFI = .97, GFI = .87). It showed good reliability (internal consistency α = .82), convergent validity and divergent validity (p < .01). The optimal cutoff point for identifying fibromyalgia women with worse daily functioning was a score of 24.5, with a sensitivity of .71 and a specificity of .75. The relevance of vigilance to pain for clinical research in fibromyalgia is discussed.

Current and future trends in psychology and chronic pain: time for a change?

Psychological approaches to chronic pain have produced significant success and are widely accepted. Yet it can be difficult for those outside the field to understand the many different variables, processes and methods that are a part of these approaches. This is partly because these approaches are characterized by a wide variety of models, each with its own primary focus and background assumptions, and these can change over time. It may be difficult to create greater consistency and integration between currently disparate psychological approaches, but there may be advantages to doing so. This integration could be helped by an appropriately designed and appropriately organizing theoretical model. It is suggested that what is called the psychological flexibility model could provide such a point of integration.

Catastrophizing-a prognostic factor for outcome in patients with low back pain: a systematic review

BACKGROUND CONTEXT

Psychological factors including catastrophizing thoughts are believed to influence the development of chronic low back pain (LBP).

PURPOSE

To assess the prognostic importance of catastrophizing as a coping strategy in patients with LBP.

STUDY DESIGN

This is a systematic review.

PATIENT SAMPLE

This study included patients with LBP.

OUTCOME MEASURES

Work-related outcomes and perceived measures including return to work, pain, and disability.

METHODS

In September 2012, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, Medline, Scopus, and Web of Science. To ensure completeness of the search, a hand search and a search of bibliographies were conducted and all relevant references included. All observational studies investigating the prognostic value of catastrophizing in patients with LBP were eligible. Included were studies with 100 and more patients and follow-up of at least 3 months. Excluded were studies with poor methodological quality, short follow-up duration, and small sample size.

RESULTS

A total of 1,473 references were retrieved, and 706 references remained after the removal of duplicates. For 77 references, the full text was assessed and 19 publications based on 16 studies were included. Of four studies that investigated work-related outcomes, two found catastrophizing to be associated with work status. Most studies that investigated self-reported outcome measures (n=8, 66%) found catastrophizing to be associated with pain and disability at follow-up in acute, subacute, and chronic LBP patients. In most studies that applied cutoff values, patients identified as high catastrophizers experienced a worse outcome compared with low catastrophizers (n=5, 83%).

CONCLUSIONS

There is some evidence that catastrophizing as a coping strategy might lead to delayed recovery. The influence of catastrophizing in patients with LBP is not fully established and should be further investigated. Of particular importance is the establishment of cutoff levels for identifying patients at risk.

Fear-avoidance beliefs-a moderator of treatment efficacy in patients with low back pain: a systematic review

BACKGROUND CONTEXT

Psychological factors are believed to influence the development of chronic low back pain. To date, it is not known how fear-avoidance beliefs (FABs) influence the treatment efficacy in low back pain.

PURPOSE

To summarize the evidence examining the influence of FABs measured with the Fear-Avoidance Belief Questionnaire or the Tampa Scale of Kinesiophobia on treatment outcomes in patients with low back pain.

STUDY DESIGN/SETTING

This is a systematic review.

PATIENT SAMPLE

Patients with low back pain.

OUTCOME MEASURES

Work-related outcomes and perceived measures including return to work, pain, and disability.

METHODS

In January 2013, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, PubMed/Medline, Scopus, and Web of Science. A hand search of the six most often retrieved journals and a bibliography search completed the search.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

research studies that included patients with low back pain who participated in randomized controlled trials (RCTs) investigating nonoperative treatment efficacy. Out of 646 records, 78 articles were assessed in full text and 17 RCTs were included. Study quality was high in five studies and moderate in 12 studies.

RESULTS

In patients with low back pain of up to 6 months duration, high FABs were associated with more pain and/or disability (4 RCTs) and less return to work (3 RCTs) (GRADE high-quality evidence, 831 patients vs. 322 in nonpredictive studies). A decrease in FAB values during treatment was associated with less pain and disability at follow-up (GRADE moderate evidence, 2 RCTs with moderate quality, 242 patients). Interventions that addressed FABs were more effective than control groups based on biomedical concepts (GRADE moderate evidence, 1,051 vs. 227 patients in studies without moderating effects). In chronic patients with LBP, the findings were less consistent. Two studies found baseline FABs to be associated with more pain and disability and less return to work (339 patients), whereas 3 others (832 patients) found none (GRADE low evidence). Heterogeneity of the studies impeded a pooling of the results.

CONCLUSIONS

Evidence suggests that FABs are associated with poor treatment outcome in patients with LBP of less than 6 months, and thus early treatment, including interventions to reduce FABs, may avoid delayed recovery and chronicity. Patients with high FABs are more likely to improve when FABs are addressed in treatments than when these beliefs are ignored, and treatment strategies should be modified if FABs are present.

Subgrouping for patients with low back pain: a multidimensional approach incorporating cluster analysis and the STarT Back Screening Tool

Early screening for psychological distress has been suggested to improve patient management for individuals experiencing low back pain. This study compared 2 approaches to psychological screening (ie, multidimensional and unidimensional) so that preliminary recommendations on which approach may be appropriate for use in clinical settings other than primary care could be provided. Specifically, this study investigated aspects of the STarT Back Screening Tool (SBT): 1) discriminant validity by evaluating its relationship with unidimensional psychological measures and 2) construct validity by evaluating how SBT risk categories compared to empirically derived subgroups using unidimensional psychological and disability measures. Patients (N = 146) receiving physical therapy for LBP were administered the SBT and a battery of unidimensional psychological measures at initial evaluation. Clinical measures consisted of pain intensity and self-reported disability. Several SBT risk-dependent relationships (ie, SBT low < medium < high risk) were identified for unidimensional psychological measure scores, with depressive symptom scores associated with the strongest influence on SBT risk categorization. Empirically derived subgroups indicated that there was no evidence of distinctive patterns among psychological or disability measures other than high or low profiles; therefore, 2 groups may provide a clearer representation of the level of pain-associated psychological distress, maladaptive coping, and disability in this setting compared with 3 groups as suggested when using the SBT in primary care settings.

PERSPECTIVE

This study suggests that the SBT can replace administering several unidimensional psychological measures as a first-line screening measure for psychological distress. However, clinicians need to be aware of the potential for misclassification with SBT results when compared to unidimensional measures. This study also suggests that a modified SBT risk stratification scheme based on empirically derived subgroups could potentially assist in identifying elevated levels of pain-associated psychological distress, maladaptive coping, and disability in practice settings outside of primary care. Patients identified with elevated levels of pain-associated distress and maladaptive coping may be indicated for additional assessment using construct-specific questionnaires.

Pain sensitivity subgroups in individuals with spine pain: potential relevance to short-term clinical outcome

BACKGROUND

Cluster analysis can be used to identify individuals similar in profile based on response to multiple pain sensitivity measures. There are limited investigations into how empirically derived pain sensitivity subgroups influence clinical outcomes for individuals with spine pain.

OBJECTIVE

The purposes of this study were: (1) to investigate empirically derived subgroups based on pressure and thermal pain sensitivity in individuals with spine pain and (2) to examine subgroup influence on 2-week clinical pain intensity and disability outcomes.

DESIGN

A secondary analysis of data from 2 randomized trials was conducted.

METHODS

Baseline and 2-week outcome data from 157 participants with low back pain (n=110) and neck pain (n=47) were examined. Participants completed demographic, psychological, and clinical information and were assessed using pain sensitivity protocols, including pressure (suprathreshold pressure pain) and thermal pain sensitivity (thermal heat threshold and tolerance, suprathreshold heat pain, temporal summation). A hierarchical agglomerative cluster analysis was used to create subgroups based on pain sensitivity responses. Differences in data for baseline variables, clinical pain intensity, and disability were examined.

RESULTS

Three pain sensitivity cluster groups were derived: low pain sensitivity, high thermal static sensitivity, and high pressure and thermal dynamic sensitivity. There were differences in the proportion of individuals meeting a 30% change in pain intensity, where fewer individuals within the high pressure and thermal dynamic sensitivity group (adjusted odds ratio=0.3; 95% confidence interval=0.1, 0.8) achieved successful outcomes.

LIMITATIONS

Only 2-week outcomes are reported.

CONCLUSIONS

Distinct pain sensitivity cluster groups for individuals with spine pain were identified, with the high pressure and thermal dynamic sensitivity group showing worse clinical outcome for pain intensity. Future studies should aim to confirm these findings.

The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review

BACKGROUND CONTEXT

Psychological factors including fear avoidance beliefs are believed to influence the development of chronic low back pain (LBP).

PURPOSE

The purpose of this study was to determine the prognostic importance of fear avoidance beliefs as assessed by the Fear Avoidance Beliefs Questionnaire (FABQ) and the Tampa Scale of Kinesiophobia for clinically relevant outcomes in patients with nonspecific LBP.

DESIGN/SETTING

The design of this study was a systematic review.

METHODS

In October 2011, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, PubMed/Medline, Scopus, and Web of Science. To ensure the completeness of the search, a hand search and a search of bibliographies was conducted and all relevant references included. A total of 2,031 references were retrieved, leaving 566 references after the removal of duplicates. For 53 references, the full-text was assessed and, finally, 21 studies were included in the analysis.

RESULTS

The most convincing evidence was found supporting fear avoidance beliefs to be a prognostic factor for work-related outcomes in patients with subacute LBP (ie, 4 weeks-3 months of LBP). Four cohort studies, conducted by disability insurance companies in the United States, Canada, and Belgium, included 258 to 1,068 patients mostly with nonspecific LBP. These researchers found an increased risk for work-related outcomes (not returning to work, sick days) with elevated FABQ scores. The odds ratio (OR) ranged from 1.05 (95% confidence interval [CI] 1.02-1.09) to 4.64 (95% CI, 1.57-13.71). The highest OR was found when applying a high cutoff for FABQ Work subscale scores. This may indicate that the use of cutoff values increases the likelihood of positive findings. This issue requires further study. Fear avoidance beliefs in very acute LBP (<2 weeks) and chronic LBP (>3 months) was mostly not predictive.

CONCLUSIONS

Evidence suggests that fear avoidance beliefs are prognostic for poor outcome in subacute LBP, and thus early treatment, including interventions to reduce fear avoidance beliefs, may avoid delayed recovery and chronicity.

What is the role of fear and escape/avoidance in chronic pain? Models, structural analysis and future directions

SUMMARY The fear-avoidance model of chronic pain has stimulated extensive research and the development of a variety of interventions focused on reducing pain-related fear, avoidance behavior and functional disability in individuals with chronic pain. Although there is considerable evidence supporting the model, oversight of potentially important factors and inconsistent findings regarding postulated pathways have led to proposed model revisions. The purpose of this brief narrative review is to provide an overview of the original model, highlight key model revisions and review existing research that directly analyzed the pathways proposed in the original and revised models. The growing body of evidence emerging from analysis of proposed fear-avoidance pathways using structural equation modeling is generally supportive of the original model, as well as various proposed revisions. Additional evaluation using structural equation modeling may lead to a formulation of the fear-avoidance model that balances parsimony with heuristic value. Clinical implications and areas for future research are discussed.

The effects of anxiety sensitivity, pain hypervigilance, and pain catastrophizing on quality of life outcomes of patients with chronic pain: a preliminary, cross-sectional analysis

PURPOSE

In the fear-avoidance model (FAM) of chronic pain, pain-related fear is one of the most prominent predictors of negative adjustment outcomes. While existing data point to the effects of anxiety sensitivity, pain hypervigilance, and pain catastrophizing on pain-related fear, the nature of their multivariate relationships remains unclear. This study explored the possible mediating role of pain hypervigilance in the relationship of anxiety sensitivity and pain catastrophizing with pain-related fear, and their effects on quality of life (QoL) outcomes within the FAM framework.

METHODS

A sample of 401 Chinese patients with chronic musculoskeletal pain completed the standardized measures assessing the FAM components and QoL. Structural equation modeling (SEM) was used to evaluate six hypothesized models.

RESULTS

Results of SEM showed adequate data-model fit [comparative fit indexes (CFIs) ranging from 0.92 to 0.94] on models which specified pain hypervigilance as mediator of anxiety sensitivity and pain catastrophizing with pain-related fear on two QoL outcomes (QoL-Physical and QoL-Mental). Results consistent with net suppression effects of pain catastrophizing on anxiety sensitivity were found in SEM when both anxiety sensitivity and pain catastrophizing were included in the same full model to predict QoL-Physical (CFI = 0.95; Sobel z = 8.06, p < 0.001) and QoL-Mental (CFI = 0.93; Sobel z = 8.31, p < 0.001).

CONCLUSIONS

These cross-sectional analyses gave results consistent with pain hypervigilance, mediating the relationship of pain catastrophic cognition and anxiety sensitivity with pain-related fear. The net suppression effects of pain catastrophizing point to anxiety sensitivity, enhancing the effect of pain catastrophic cognition on pain hypervigilance. These findings elucidate how the interdependence of dispositional factors might influence pain adjustment and functioning.

Influence of catastrophizing on treatment outcome in patients with nonspecific low back pain: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVE

The aim of this study was to assess the effect of catastrophizing on treatment efficacy and outcome in patients treated for low back pain.

SUMMARY OF BACKGROUND DATA

Psychological factors including catastrophizing thoughts are thought to increase the risk for chronic low back pain. The influence of catastrophizing is debated.

METHODS

In September 2012, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, EMBASE, OTseeker, PeDRO, PsycINFO, MEDLINE, Scopus, and Web of Science. For 50 of 706 references, full text was assessed. Results based on 11 studies were included in this analysis.

RESULTS

In the 11 studies, a total of 2269 patients were included. Seven studies were of good and 4 of moderate methodological quality. Heterogeneity in study settings, treatments, outcomes, and patient populations impeded meta-analysis. Catastrophizing at baseline was predictive for disability at follow-up in 4 studies and for pain in 2 studies. Three studies found no predictive effect of catastrophizing. A mediating effect was found in all studies (n = 5) assessing the impact of a decrease in catastrophizing during treatment. A greater decrease was associated with better outcome. Most studies that investigated the moderating effects on treatment efficacy found no effect (n = 5). However, most studies did not look for a direct interaction between the treatment and catastrophizing thoughts. No study investigated the influence of catastrophizing on work-related outcomes including return to work.

CONCLUSION

Catastrophizing predicted degree of pain and disability and mediated treatment efficacy in most studies. The presence of catastrophizing should be considered in patients with persisting back pain. Limited evidence was found for the moderating effects on treatment efficacy. Future research should aim to clarify the role of catastrophizing as a moderator of outcome and investigate its importance for work-related outcomes.

LEVEL OF EVIDENCE

1.

Predictive factors for successful clinical outcome 1 year after an intensive combined physical and psychological programme for chronic low back pain

PURPOSE

The aim of this longitudinal study is to determine the factors which predict a successful 1-year outcome from an intensive combined physical and psychological (CPP) programme in chronic low back pain (CLBP) patients.

METHODS

A prospective cohort of 524 selected consecutive CLBP patients was followed. Potential predictive factors included demographic characteristics, disability, pain and cognitive behavioural factors as measured at pre-treatment assessment. The primary outcome measure was the oswestry disability index (ODI). A successful 1-year follow-up outcome was defined as a functional status equivalent to 'normal' and healthy populations (ODI ≤22). The 2-week residential programme fulfills the recommendations in international guidelines. For statistical analysis we divided the database into two equal samples. A random sample was used to develop a prediction model with multivariate logistic regression. The remaining cases were used to validate this model.

RESULTS

The final predictive model suggested being 'in employment' at pre-treatment [OR 3.61 (95 % CI 1.80-7.26)] and an initial 'disability score' [OR 0.94 (95 % CI 0.92-0.97)] as significant predictive factors for a successful 1-year outcome (R (2) = 22 %; 67 % correctly classified). There was no predictive value from measures of psychological distress.

CONCLUSION

CLBP patients who are in work and mild to moderately disabled at the start of a CPP programme are most likely to benefit from it and to have a successful treatment outcome. In these patients, the disability score falls to values seen in healthy populations. This small set of factors is easily identified, allowing selection for programme entry and triage to alternative treatment regimes.

Prognostic factors for return to work in patients with sciatica

BACKGROUND CONTEXT

Little is known about the prognostic factors for work-related outcomes of sciatica caused by disc herniation.

PURPOSE

To identify the prognostic factors for return to work (RTW) during a 2-year follow-up among sciatica patients referred to secondary care.

STUDY DESIGN/SETTING

Multicenter prospective cohort study including 466 patients. Administrative data from the National Sickness Benefit Register were accessed for 227 patients.

PATIENT SAMPLE

Two samples were used. Sample A comprised patients who at the time of inclusion in the cohort reported being on partial sick leave or complete sick leave or were undergoing rehabilitation because of back pain/sciatica. Sample B comprised patients who, according to the sickness benefit register, at the time of inclusion received sickness benefits or rehabilitation allowances because of back pain/sciatica.

OUTCOME MEASURES

In Sample A, the outcome was self-reported return to full-time work at the 2-year follow-up. In Sample B, the outcome was time to first sustained RTW, defined as the first period of more than 60 days without receiving benefits from the register.

METHODS

Significant baseline predictors of self-reported RTW at 2 years (Analysis A) were identified by multivariate logistic regression. Significant predictors of time to sustained RTW (Analysis B) were identified by multivariate Cox proportional hazard modeling. Both analyses included adjustment for age and sex. To assess the effect of surgery on the probability of RTW, analyses similar to A and B were performed, including the variable surgery (yes/no).

RESULTS

One-fourth of the patients were still out of work at the 2-year follow-up. In Sample A (n=237), younger age, better general health, lower baseline sciatica bothersomeness, less fear-avoidance work, and a negative straight-leg-raising test result were significantly associated with a higher probability of RTW at the 2-year follow-up. Surgery was not significantly associated with the outcome. In Sample B (n=125), history of sciatica, duration of the current sciatica episode more than 3 months, greater sciatica bothersomeness, fear-avoidance work, and back pain were significantly associated with a longer time to sustained RTW. Surgery was significantly negatively associated with time to sustained RTW both in univariate (hazard ratio [HR] 0.60; 95% confidence interval [CI] 0.39, 0.93; p=.02) and in multivariate (HR 0.49; 95% CI 0.31, 0.79; p=.003) analyses.

CONCLUSIONS

The baseline factors associated with RTW identified in multivariate analysis were age, general health, history of sciatica, duration of the current episode, baseline sciatica bothersomeness, fear-avoidance work, back pain, and the straight-leg-raising test result. Surgical treatment was associated with slower RTW, but surgical patients were more severely affected than patients treated without surgery; so, this finding should be interpreted with caution.

Factors associated with fear-avoidance beliefs about low back pain

BACKGROUND

Low back pain (LBP) is a common major health problem. Fear-avoidance beliefs are thought to be an important risk factor for chronic LBP. This study investigated factors associated with the Fear-Avoidance Beliefs Questionnaire (FABQ) scores of Japanese adults who experienced LBP. We focused on the association of FABQ scores with medical advice to rest and the experience of seeing family members and/or significant others with disabling LBP.

METHODS

In February 2011, 1,063,083 adults aged 20-79 years who had registered as internet-based research volunteers were randomly selected and invited to participate in a questionnaire survey. The data from 52,650 respondents who had experienced LBP were analyzed. Multiple linear regression analysis was used to examine the association between FABQ physical activity scores and the advice for respondents with LBP to rest, the experience of seeing others with disabling LBP, and other personal and LBP factors.

RESULTS

After controlling for age, sex, and lifetime and current LBP disability grades, the experience of seeing others with disabling LBP (regression coefficient β = 0.94), rest advice (β = 0.91), history of chronic LBP (β = 0.78), radiating pain below the knee (β = 0.44), and workers' compensation (β = 0.51) were associated with higher FABQ physical activity scores. Conversely, regular exercise (β = -0.89) and LBP attributed to sports (β = -0.76) were associated with lower FABQ physical activity scores.

CONCLUSION

The association between rest advice and higher fear-avoidance beliefs supports the recent treatment guidelines that emphasize continuation of daily activities.

STUDY DESIGN

cross-sectional study.

Psychological factors and treatment opportunities in low back pain

A large body of evidence suggests that psychological factors, including emotions, beliefs and avoidant behaviours, are linked to poor outcomes in low back pain. At the same time, the evidence from trials of psychological interventions suggests that they improve outcomes mostly in the short term and against passive controls only. These suboptimal results may be due to low competency or fidelity in delivery, or inadequate matching of treatment methods with specific patient problems. Most importantly, there is insufficient theoretical guidance and integration in the design, selection and delivery of methods that precisely target known process of pathology. We identify several new directions for research and opportunities to improve the impact of psychological interventions and to change clinical practice. These include better ways to conceptualise and deliver reassurance at early stages of back pain, utilising models such as the psychological flexibility model to guide treatment development, and essentially extend the fear-avoidance model.

Relationship between different measures of pain-related fear and physical capacity of the spine in patients with chronic low back pain

BACKGROUND CONTEXT

It has been controversially stated that pain-related fear is a more important determining factor for disability in chronic low back pain (CLBP) than pain or physical impairment in itself. So far, the relationship between psychological and physiological determinants of chronic pain, that is, pain-related fear and physiological abilities, remains unclear.

PURPOSE

To evaluate whether pain-related fear assessed by different tools (both task specific and non task specific) is related to physical capacity measured by specific spine tests and, secondarily, to explore the relationship between different pain-related fear assessment tools.

STUDY DESIGN/SETTING

Cross-sectional study.

PATIENT SAMPLE

Fifty patients with CLBP (50% women; meanage [standard deviationage]: 44.2 [9.5 years]).

OUTCOME MEASURES

Physical capacity by means of three specific spine tests, that is, the finger-floor distance test (flexibility), a maximal isometric strength test of trunk extensor muscles (strength), and the Sorensen test (endurance). Pain-related fear by means of self-report measures, that is, the Tampa Scale for Kinesiophobia (TSK), the Photograph Series of Daily Activities (PHODA), and a fear visual analog scale (FVAS) tailored to the spine tests.

METHODS

Participants were asked to complete the TSK and PHODA and to perform the three spine tests. Right before performing each of the spine tests, an FVAS was filled out. Linear regression analyses controlling for gender and age were performed to study the association between the pain-related fear measurements and the results of the spine tests. To investigate the relationship between the pain-related fear measurements, correlation tests were performed.

RESULTS

The linear regression analyses revealed that neither the TSK and PHODA scores nor the FVAS scores were significantly related to the physical capacity measurements. The correlational tests showed no significant correlation between the PHODA, TSK, and FVAS scores.

CONCLUSIONS

The present study shows that neither the task-specific tool (FVAS) nor the non task-specific questionnaires (TSK and PHODA) were significantly correlated to the spine tests in patients with CLBP. This is contrary to earlier evidence according to which physical capacity is inversely related to the level of pain-related fear, and it suggests that one should not draw conclusions about physical capacity based on pain-related fear scores. Furthermore, the different assessment tools for pain-related fear were surprisingly not correlated with each other.

Effects of behavioural exercise therapy on the effectiveness of a multidisciplinary rehabilitation for chronic non-specific low back pain: study protocol for a randomised controlled trial

BACKGROUND

In Germany, a multidisciplinary rehabilitation named "behavioural medical rehabilitation" (BMR) is available for treatment of chronic low back pain (clbp). A central component of BMR is standard exercise therapy (SET), which is directed mainly to improve physical fitness. There is a need to address psychosocial factors within SET and therefore to improve behavior change with a focus on the development of self-management skills in dealing with clbp. Furthermore, short-term effectiveness of BMR with a SET has been proven, but the impact of a behavioural exercise therapy (BET) for improvement of the long-term effectiveness of BMR is unclear.

METHODS/DESIGN

To compare the effectiveness of two exercise programs with different approaches within BMR on the effects of BMR a prospective randomized controlled trial (RCT) in two rehabilitation centres will be performed. 214 patients aged 18-65 with clbp will be, based on an "urn randomisation"-algorithm, randomly assigned to a BMR with SET (function-oriented, n=107) and BMR with BET (behaviour-oriented, n=107). Both exercise programs have a mean duration of 26 hours in three weeks and are delivered by a limited number of not-blinded study therapists in closed groups with six to twelve patients who will be masked regarding study group. The main differences of BET lie in its detailed manualised program with a theory-based, goal-orientated combination of exercise, education and behavioural elements, active participation of patients and consideration of their individual preferences and previous experiences with exercise. The primary outcome is functional ability assessed with the Hannover Functional Ability Questionnaire directly before and after the rehabilitation program, as well as a six and twelve-month follow-up.

DISCUSSION

This RCT is designed to explore the effects of BET on the effectiveness of a BMR compared to a BMR with SET in the management of patients with clbp. Methodological challenges arise from conducting a RCT within routine health care as well as from ensuring high treatment integrity. Findings of this study might contribute to a better understanding of the mechanism of action of BMR and the special effects of BET and may be used to improve the quality of these interventions in routine care, therefore reducing the burden to patients with disabling clbp.

TRIAL REGISTRATION

Current controlled trials NCT01666639.

The STarT back screening tool and individual psychological measures: evaluation of prognostic capabilities for low back pain clinical outcomes in outpatient physical therapy settings

BACKGROUND

Psychologically informed practice emphasizes routine identification of modifiable psychological risk factors being highlighted.

OBJECTIVE

The purpose of this study was to test the predictive validity of the STarT Back Screening Tool (SBT) in comparison with single-construct psychological measures for 6-month clinical outcomes.

DESIGN

This was an observational, prospective cohort study.

METHODS

Patients (n=146) receiving physical therapy for low back pain were administered the SBT and a battery of psychological measures (Fear-Avoidance Beliefs Questionnaire physical activity scale and work scale [FABQ-PA and FABQ-W, respectively], Pain Catastrophizing Scale [PCS], 11-item version of the Tampa Scale of Kinesiophobia [TSK-11], and 9-item Patient Health Questionnaire [PHQ-9]) at initial evaluation and 4 weeks later. Treatment was at the physical therapist's discretion. Clinical outcomes consisted of pain intensity and self-reported disability. Prediction of 6-month clinical outcomes was assessed for intake SBT and psychological measure scores using multiple regression models while controlling for other prognostic variables. In addition, the predictive capabilities of intake to 4-week changes in SBT and psychological measure scores for 6-month clinical outcomes were assessed.

RESULTS

Intake pain intensity scores (β=.39 to .45) and disability scores (β=.47 to .60) were the strongest predictors in all final regression models, explaining 22% and 24% and 43% and 48% of the variance for the respective clinical outcome at 6 months. Neither SBT nor psychological measure scores improved prediction of 6-month pain intensity. The SBT overall scores (β=.22) and SBT psychosocial scores (β=.25) added to the prediction of disability at 6 months. Four-week changes in TSK-11 scores (β=-.18) were predictive of pain intensity at 6 months. Four-week changes in FABQ-PA scores (β=-.21), TSK-11 scores (β=-.20) and SBT overall scores (β=-.18) were predictive of disability at 6 months.

LIMITATIONS

Physical therapy treatment was not standardized or accounted for in the analysis.

CONCLUSIONS

Prediction of clinical outcomes by psychology-based measures was dependent upon the clinical outcome domain of interest. Similar to studies from the primary care setting, initial screening with the SBT provided additional prognostic information for 6-month disability and changes in SBT overall scores may provide important clinical decision-making information for treatment monitoring.

Low back pain subgroups using fear-avoidance model measures: results of a cluster analysis

OBJECTIVES

The purpose of this secondary analysis was to test the hypothesis that an empirically derived psychological subgrouping scheme based on multiple Fear-Avoidance Model (FAM) constructs would provide additional capabilities for clinical outcomes in comparison with a single FAM construct.

METHODS

Patients (n=108) with acute or subacute low back pain enrolled in a clinical trial comparing behavioral physical therapy interventions to classification-based physical therapy completed baseline questionnaires for Pain Catastrophizing Scale, fear-avoidance beliefs [Fear-Avoidance Beliefs Questionnaire (FABQ)-physical activity scale (PA), FABQ work scale], and patient-specific fear (Fear of Daily Activities Questionnaire). Clinical outcomes included pain intensity and disability measured at baseline, 4 weeks, and 6 months. A hierarchical agglomerative cluster analysis was used to create distinct cluster profiles among the FAM measures and discriminant analysis was used to interpret clusters. Changes in clinical outcomes were investigated with repeated measures analysis of variance and differences in results based on cluster membership were compared with FABQ-PA subgrouping used in the original trial.

RESULTS

Three distinct FAM subgroups (Low-Risk, High Specific Fear, and High Fear and Catastrophizing) emerged from cluster analysis. Subgroups differed on baseline pain and disability (P<0.01) with the High Fear and Catastrophizing subgroup associated with greater pain than the Low-Risk subgroup (P<0.01) and the greatest disability (P<0.05). Subgroup×time interactions were detected for both pain and disability (P<0.05) with the High Fear and Catastrophizing subgroup reporting greater changes in pain and disability than other subgroups (P<0.05). In contrast, FABQ-PA subgroups used in the original trial were not associated with interactions for clinical outcomes.

DISCUSSION

These data suggest that subgrouping based on multiple FAM measures may provide additional information on clinical outcomes in comparison with determining subgroup status by FABQ-PA alone. Subgrouping methods for patients with low back pain should include multiple psychological factors to further explore if patients can be matched with appropriate interventions.

Activity pacing, avoidance, endurance, and associations with patient functioning in chronic pain: a systematic review and meta-analysis

OBJECTIVE

To systematically review the associations between different approaches to activity (ie, activity pacing, avoidance, or endurance) and indicators of patient functioning in chronic pain samples.

DATA SOURCES

A key word search was conducted in PsycINFO, MEDLINE via Ovid, EMBASE, and PubMed up to March 2011.

STUDY SELECTION

To be included, studies had to (1) be written in English, (2) report on an adult chronic pain sample, and (3) report a correlation coefficient between at least 1 measure of 1 of the 3 "approach to activity" variables and an indicator of patient functioning.

DATA EXTRACTION

Two reviewers independently screened abstracts and full-text articles for eligibility and extracted the data. Results of correlation analyses were grouped on the basis of measure of approach to activity (pacing/avoidance/endurance) and the criterion variable measured (pain/physical functioning/psychological functioning), resulting in 9 categories. Random-effects modeling was then used to pool data across studies in each category.

DATA SYNTHESIS

Forty-one studies were eligible for inclusion. Results demonstrated that avoidance of activity was consistently associated with more pain, poorer psychological functioning, and more physical disability. While enduring with activity was associated with enhanced physical and psychological functioning, these relationships appeared to be dependent on the measure used, with measures more reflective of persisting with activities to the point of severe pain aggravation (overactivity) linked to poorer outcomes. Pacing was generally linked to better psychological functioning but more pain and disability.

CONCLUSIONS

Although causation cannot be determined, results of this study suggest that both avoidance of activity and overactivity are associated with poorer patient outcomes. Unexpected results relating to pacing may reflect either the ineffectiveness of pacing if not used to gradually increase an individual's activity level or the notion that individuals with better psychological functioning but more pain and disability are more inclined to pace activity.

Pathoanatomy and classification of low back disorders

Over the past decade research into the effectiveness of low back disorders (LBDs) has focused on the classification of subgroups more likely to respond to specific treatment. Much of this research has explicitly excluded a focus on pathoanatomical factors based on a questionable interpretation of the biopsychosocial model. Common justifications and potential issues with this approach are explored with recommendations made for future clinical and research practice.

Non-specific low back pain

Non-specific low back pain has become a major public health problem worldwide. The lifetime prevalence of low back pain is reported to be as high as 84%, and the prevalence of chronic low back pain is about 23%, with 11-12% of the population being disabled by low back pain. Mechanical factors, such as lifting and carrying, probably do not have a major pathogenic role, but genetic constitution is important. History taking and clinical examination are included in most diagnostic guidelines, but the use of clinical imaging for diagnosis should be restricted. The mechanism of action of many treatments is unclear, and effect sizes of most treatments are low. Both patient preferences and clinical evidence should be taken into account for pain management, but generally self-management, with appropriate support, is recommended and surgery and overtreatment should be avoided.

Fear-avoidance beliefs and pain avoidance in low back pain--translating research into clinical practice

BACKGROUND CONTEXT

For patients with low back pain, fear-avoidance beliefs (FABs) represent cognitions and emotions that underpin concerns and fears about the potential for physical activities to produce pain and further harm to the spine. Excessive FABs result in heightened disability and are an obstacle for recovery from acute, subacute, and chronic low back pain.

PURPOSE

This article summarizes past research concerning the etiology, impact, and assessment of FABs; reviews the results and relevance to clinical practice of trials that have addressed FAB as part of low back pain treatment; and lists areas in need of further study.

STUDY DESIGN

This article reports on a plenary presentation and discussion of an expert panel and workshop entitled "Addressing fear-avoidance beliefs in a fear-avoidant world--translating research into clinical practice" that was held at Forum X, Primary Care Research on Low Back Pain, during June 2009, at the Harvard School of Public Health in Boston, MA, USA.

METHODS

Important issues including the definition, etiology, impact, and treatment of FAB on low back pain outcomes were reviewed by six panelists with extensive experience in FAB-related research. This was followed by a group discussion among 40 attendees. Conclusion and recommendations were extracted by the workshop panelist and summarized in this article.

RESULTS

Fear-avoidance beliefs are derived from both emotionally based fears of pain and injury and information-based beliefs about the soundness of the spine, causes of spine degeneration, and importance of pain. Excessively elevated FABs, both in patients and treating health care providers, have a negative impact on low back pain outcomes as they delay recovery and heighten disability. Fear-avoidance beliefs may be best understood when patients are categorized into subgroups of misinformed avoiders, learned pain avoiders, and affective avoiders as these categories elucidate potential treatment strategies. These include FAB-reducing information for misinformed avoiders, pain desensitizing treatments for pain avoiders, and fear desensitization along with counseling to address the negative cognition in affective avoiders. Although mixed results have been noted, most clinical trials have documented improved outcomes when FAB is addressed as part of treatment. Deficiencies in knowledge about brief methods for assessing FAB during clinical encounters, the importance of medical explanations for back pain, usefulness of subgroup FABs, core points for information-based treatments, and efficient strategies for transferring FAB-reducing information to patients hamper the translation of FAB research into clinical practice.

CONCLUSIONS

By incorporating an understanding of FAB, clinicians may enhance their ability to assess the predicaments of their patients with low back pain and gain insight into potential value of corrective information that lessen fears and concerns on well-being of their patients.