The treatment of fear of movement/(re)injury in chronic low back pain: further evidence on the effectiveness of exposure in vivo

Fear of pain in the context of intensive pain rehabilitation among children and adolescents with neuropathic pain: associations with treatment response

Recent research has implicated pain-related fear in relation to functional outcomes in children with chronic pain. The current study examined fear of pain, disability, and depression within the context of an intensive pain rehabilitation program. One hundred forty-five children and adolescents who participated in an intensive interdisciplinary pediatric pain rehabilitation day program were assessed in this study. Patients completed measures of pain intensity, pain-related fears, functional disability, and depressive symptoms at admission, discharge, and on average, 2 months postdischarge. After controlling for pain intensity, pain-related fear was significantly related to disability and depressive symptoms at all time points. As predicted, a decline in pain-related fear was significantly associated with a decrease in disability and depressive symptoms. Interestingly, high levels of pain-related fears at admission predicted less reduction in functional disability and depression at discharge, suggesting that high levels of pain-related fear may be a risk factor in relation to treatment outcomes. Overall, results indicate that the relationship between fear of pain and changes in disability and depressive symptoms are closely linked, with fear of pain playing an important role in treatment.

PERSPECTIVE

This paper presents results underscoring the importance of pain-related fear in relation to treatment response for children and adolescents with chronic pain. These findings support the need to develop and implement interventions that target reductions in pain-related fear.

The Fear Avoidance model of chronic pain: examination for pediatric application

The current study examined the Fear Avoidance (FA) model of chronic pain in pediatric chronic pain patients. Multiple structural equation models were tested in the current study with pairwise parameter comparisons made between younger children (8-12 years) and adolescents (13-17 years). Within a sample of 350 children and adolescents, we examined functional disability and depressive symptoms in separate models with the following predictor variables-pain, pain catastrophizing, fear of pain, and avoidance of activities-after controlling for duration of pain. For a subset of patients (n = 151), we also tested a brief prospective outcome model with baseline predictor variables and functional disability at 1-month follow-up. The FA models predicting functional disability concurrently and prospectively were an excellent fit to the data. The theorized FA model for depression was a poor fit. When the model was modified to include direct pathways from the cognitive processes of pain catastrophizing and fear of pain to depressive symptoms, the model fit was significantly improved. In the examination of developmental differences between younger children and adolescent patients, duration of pain contributed to the model for younger children, whereas pain-related fears were more influential for adolescent patients.

PERSPECTIVE

The FA model of chronic pain appears to be applicable for pediatric patients with some modification to account for developmental differences across childhood. We discuss the developmental, theoretical, and clinical implications of these results.

Psychological interventions for chronic pain: reviewed within the context of goal pursuit

SUMMARY In contemporary psychological interventions for chronic pain, cognitive-behavioral therapy takes a central role, covering a broad range of techniques and aims. To improve the effectiveness of cognitive-behavioral therapy and to refine its components, new theoretical approaches may help understand and arrange the mechanisms underlying pain perception, behavior and suffering. This article reviews processes of change in cognitive-behavioral therapies for chronic pain within the context of goal pursuit. Treatments are viewed from the perspective of the action phase model of goal attainment. With this model in mind, a distinction is made between goal ‘intentions’ and their ‘realization’. In addition, recent research findings on goal pursuit in the context of (chronic) pain are reviewed, with a special emphasis on their implications for clinical practice.

Injured workers' construction of expectations of return to work with sub-acute back pain: the role of perceived uncertainty

INTRODUCTION

Little is known about the formation of expectations of return to work (RTW) from the perspective of injured workers with back injuries. This modified grounded theory study uses a biopsychosocial approach that considers the workers' complex social circumstances, to unpack the multidimensional construct of expectations of RTW from the injured worker's perspective.

METHOD

Initial semi-structured interviews were conducted with 18 individuals with sub-acute back pain, who were off work between 3 and 6 months. Follow-up interviews were conducted with 7 participants for the purposes of member checking. The interview data was coded, compared and analyzed over the course of data collection, until saturation was reached.

RESULTS

Data analysis revealed that expectations of return-to-work are constructed based on perceived uncertainty which subsumes five inter-related categories (1) perceived lack of control over the return-to-work process, (2) perceived lack of recognition by others of the impact of the injury, (3) perceived inability to perform the pre-injury job, (4) fear of re-injury, and (5) perceived need for workplace accommodations. Expectations, once formed, were influenced by the worker's experience of coping with perceived uncertainty.

CONCLUSION

Perceived uncertainty plays a key role in injured workers' formation of expectations of return-to-work. Implications are discussed regarding how this perceived uncertainty plays a role in the development of (re)injury prevention and rehabilitation programs. The importance of further research on perceived uncertainty is presented, along with potential future research considerations.

Kinesiophobia, catastrophizing and anticipated symptoms before stair climbing in chronic fatigue syndrome: an experimental study

PURPOSE

Kinesiophobia and catastrophizing are frequent among people with chronic fatigue syndrome (CFS). This study was aimed at examining (1) whether kinesiophobia, anticipated symptoms and fatigue catastrophizing are related to stair climbing performance in people with CFS; and (2) whether kinesiophobia and fatigue catastrophizing are related to daily physical activity in CFS.

METHOD

Patients with CFS filled in a set of questionnaires, performed a physical demanding task (two floors stair of climbing and descending) with pre-test and post-test heart rate monitoring and immediate post-stair climbing symptom assessment. Real-time activity monitoring was used between the baseline and second assessment day (7 days later).

RESULTS

Kinesiophobia and fatigue catastrophizing were strongly related (ρ = 0.62 and 0.67, respectively) to poorer stair climbing performance (i.e. more time required to complete the threatening activity). Kinesiophobia and fatigue catastrophizing were unrelated to the amount of physical activity on the first day following stair climbing or during the seven subsequent days.

CONCLUSION

These findings underscore the importance of kinesiophobia and fatigue catastrophizing for performing physical demanding tasks in everyday life of people with CFS, but refute a cardinal role for kinesiophobia and fatigue catastrophizing in determining daily physical activity level in these patients.

Brief Fear of Movement Scale for osteoarthritis

OBJECTIVE

Fear of movement has important clinical implications for individuals with osteoarthritis (OA). This study aimed to establish a brief fear of movement scale for use in OA. Items from the Tampa Scale for Kinesiophobia (TSK) were examined.

METHODS

The English version of the TSK was examined in a community-based sample (n = 1,136) of individuals with OA of the hip or knee. Exploratory and confirmatory factor analyses were used to determine the number and content of the dimensions of fear of movement. Factorial invariance was tested across subgroups of sex, race, education, and OA severity. Convergent validity with measures of pain, physical functioning, and psychological functioning was examined.

RESULTS

Factor analyses identified a single-factor 6-item scale that measures activity avoidance due to pain-related fear of movement (confirmatory factor analysis indices of model fit: root mean square error of approximation = 0.04, standardized root mean square residual = 0.01, comparative fit index = 0.99, and Tucker-Lewis Index = 0.99). The 6-item scale demonstrated factorial invariance across sex, race, levels of education, and OA severity, suggesting that this scale performs consistently across diverse groups of individuals with OA. Convergent validity with measures of pain (β = 0.30-0.41), physical functioning (β = 0.44-0.48), and psychological functioning (β = 0.36-0.37) was also demonstrated.

CONCLUSION

The Brief Fear of Movement Scale identified in this study provides a promising and valid approach for assessing fear of movement in individuals with OA. This brief scale demonstrated several important strengths, including a small number of items, sound psychometric properties, and consistent performance across diverse groups of individuals with OA.

Spouse-assisted training in pain coping skills and the outcome of multidisciplinary pain management for chronic low back pain treatment: a 1-year randomized controlled trial

This study examined the comparative efficacy of three interventions: a spouse-assisted coping skills training protocol for patients undergoing a multidisciplinary pain management programme (SA-MPMP), conventional patient-oriented multidisciplinary pain management programme (P-MPMP) and standard medical care (SMC). Thirty-six chronic low back pain (CLBP) patients and their spouses were randomly assigned to one of the three conditions. The SA-MPMP condition consisted of seven, weekly, 2-h, group sessions of training in dyadic pain coping and couple skills, delivered by a clinical psychologist with support of a multidisciplinary team of specialists, to patients together with their spouses. P-MPMP consisted of the SA-MPMP training delivered to the patient only (i.e., no spouse participation and assistance). The SMC condition entailed continuation of routine treatment, entailing medical care only. Data analysis revealed that, at the 12-month follow-up time point, patients receiving SA-MPMP had significant improvements in kinesiophobia and rumination about pain compared to those receiving P-MPMP and SMC. In patients suffering from CLBP, an intervention that combines spouse-assisted coping skills training with a multidisciplinary pain management programme can improve fear of movement and rumination about low back pain.

Pain and pain-related fear are associated with functional and social disability in an occupational setting: Evidence of mediation by pain-related fear

This study examined the role of work-related, psychosocial and psychological factors in predicting functional and social disability in working employees. In a cross-sectional design, 890 working employees (reporting at least 1 day of back pain during the past year) completed self-report measures of back pain, disability, pain-related fear, negative and positive affectivity, job satisfaction, job stress and physical work load. Regression analyses revealed that pain intensity was a strong predictor of functional (beta = .69, p < .001) and social disability (beta = .67, p < .001). Fear of (re)injury due to movement (beta = .25, p < .001; beta = .28, p < .001) had additional predictive value in both models. Further, (singular) mediation tests indicated that fear for (re)injury partially mediated the relation between pain intensity and disability, and between negative affectivity and disability. Finally, path analyses revealed both fear and pain intensity as mediators between negative affectivity and disability. Overall, our findings point at the relevance of the cognitive-behavioral model of avoidance in occupational settings.

Decline in physical activity, disability and pain-related fear in sub-acute low back pain

AIM OF INVESTIGATION

To evaluate whether a perceived decline in the level of physical activity after the onset of pain (PAD) is more appropriate in the explanation of disability as compared to the actual level of physical activity (PAL) in patients with sub-acute back pain.

METHODS

Patients with 4-7 weeks of non-specific low back pain (LBP) participated in this study. Their habitual physical activity level before the back pain started (H-PAL), their actual level of physical activity (PAL) and their perceived decline in the level of physical activity after the onset of pain (PAD) were assessed. The association between these physical activity related variables and perceived disability (QBPDS), fear of movement/(re)injury (TSK), pain catastrophizing (PCS) and pain intensity (VAS) was examined. The role of PAD as a mediator in the association between fear of movement/(re)injury and disability was examined by three linear regression analyses.

RESULTS

123 patients (66 male and 57 female) with a mean age of 44.1 years (SD=10.3) participated in this study. PAD was significantly correlated with disability, fear of movement/(re)injury, pain catastrophizing and pain intensity. PAD and PAL appeared more important in the explanation of disability in the subgroup of patients who were physically active before their back pain started. Generally, PAD indeed mediated the association between fear of movement/(re)injury and disability.

CONCLUSIONS

The perceived decline in physical activity, rather than the current physical activity itself is important in the evaluation of the impact of activity related changes on disability in low back pain.

Impaired disengagement from threatening cues of impending pain in a crossmodal cueing paradigm

This paper reports an experimental investigation of attentional engagement to and disengagement from cues of impending pain. Pain-free volunteers performed a cueing task in which they were instructed to detect somatosensory and tone targets. Target stimuli were preceded by visual cues informing participants of the modality of the impending stimuli. Participants were randomly assigned to a pain group (n = 54) or to a control group (n = 53). Somatosensory targets consisted of painful electrocutaneous stimuli in the pain group and non-painful vibrotactile targets in the control group. Analyses revealed a similar amount of attentional engagement to both cues signalling somatosensory targets, irrespective of their threat value. However, participants had significantly more difficulty in disengaging attention from a threatening cue of impending pain compared to a cue signalling the non-painful vibrotactile target. Our findings provide further evidence that pain cues demand attention, particularly resulting in impaired disengagement.

Pain-related fear in low back pain: A prospective study in the general population

A cognitive behavioural account of chronic low back pain (CLBP) proposes that the relationship between pain catastrophizing and functional disability is mediated by fear of movement/(re)injury. Several clinical studies already demonstrated the contribution of pain catastrophizing and fear of movement/(re)injury in the development and maintenance of CLBP. This study included people with low back pain (LBP) in the general population, and aimed to investigate whether fear of movement/(re)injury mediated the relationship between pain catastrophizing and functional disability, by examining several prerequisites for mediation. Data from the Dutch population-based Musculoskeletal Complaints and Consequences Cohort (DMC(3)) study were used, including 152 people suffering from LBP who completed both a follow-up questionnaire and a baseline questionnaire 6 months previously. This study was unable to demonstrate that the relationship between pain catastrophizing and functional disability was mediated by fear of movement/(re)injury, since the prerequisite that pain catastrophizing and functional disability were related, was not fulfilled. However, pain catastrophizing was significantly related to fear of movement/(re)injury 6 months later, above and beyond other contributing variables such as fear of movement/(re)injury already present at baseline. On its turn, fear of movement/(re)injury was related to functional disability, in addition to pain intensity. Although this study leaves some indistinctness concerning the actual relationships between pain catastrophizing, fear of movement/(re)injury, and functional disability, it does provide some evidence for the contributing role of these factors in LBP in the general population.

Self-efficacy mediates the relation between pain-related fear and outcome in chronic low back pain patients

This study aimed to determine whether self-efficacy beliefs mediated the relation between pain-related fear and pain, and between pain-related fear and disability in CLBP patients who exhibited high pain-related fear. In a cross-sectional design, 102 chronic low back pain (CLBP) patients completed measures for pain, disability, self-efficacy and pain-related fear (fear of movement and catastrophizing). Multistep regression analyses were performed to determine whether self-efficacy mediated the relation between pain-related fear and outcome (pain and/or disability). Self-efficacy was found to mediate the relation between pain-related fear and pain intensity, and between pain-related fear and disability. Therefore, this study suggests that when self-efficacy is high, elevated pain-related fear might not lead to greater pain and disability. However, in instances where self-efficacy is low, elevated pain-related fear is likely to lead to greater pain and disability. In view of these findings, we conclude that it is imperative to assess both pain-related fear and self-efficacy when treating CLBP patients with high pain-related fear.

The relation between cognitive factors and levels of pain and disability in chronic low back pain patients presenting for physiotherapy

The aim of this study was to determine the extent to which a number of distinct cognitive factors were differentially related to the levels of pain and disability reported by 183 chronic low back pain (CLBP) patients presenting for physiotherapy. After adjusting for demographics, the cognitive factors accounted for an additional 30% of the variance in pain intensity, with functional self-efficacy (beta=-0.40; P<0.001) and catastrophizing (beta=0.21; P<0.01) both uniquely contributing to the prediction of outcome. The cognitive factors also explained an additional 32% of the variance in disability after adjusting for demographics and pain intensity (total R(2)=0.61). Higher levels of functional self-efficacy (beta=-0.43; P<0.001) and lower levels of depression (beta=0.23; P<0.01) were uniquely related to lower levels of disability. Our findings clearly show that there is a strong association between cognitive factors and the levels of pain and disability reported by CLBP patients presenting for physiotherapy. Functional self-efficacy emerged as a particularly strong predictor of both pain intensity and disability. In view of our findings it would seem that targeting specific cognitive factors should be an integral facet of physiotherapy-based treatments for CLBP.

Catastrophizing during and after pregnancy: associations with lumbopelvic pain and postpartum physical ability

BACKGROUND

There is a lack of knowledge about the possible role of catastrophizing in lumbopelvic pain during and after pregnancy and in postpartum physical ability.

OBJECTIVE

The aims of this study were to explore how catastrophizing fluctuates over time during and after pregnancy and to investigate the associations between catastrophizing and lumbopelvic pain and between catastrophizing and postpartum physical ability.

DESIGN

A prospective questionnaire was used.

METHODS

The Pain Catastrophizing Scale was used to assess exaggerated negative thoughts about pain experiences in weeks 19 to 21 and weeks 34 to 37 of pregnancy and at 6 months postpartum. The Disability Rating Index was used to assess physical ability at 6 months postpartum. The occurrence of lumbopelvic pain was reported by participants. Parametric and nonparametric tests were used for the analyses.

RESULTS

A total of 242 of 324 women were categorized according to reported levels of catastrophizing. A majority of women (57.9%) reported not catastrophizing at all test occasions, whereas 10.3% reported catastrophizing at all occasions. For the remaining 31.8%, the levels of catastrophizing varied over time. Women who catastrophized at 1 or more of the occasions reported higher proportions of postpartum lumbopelvic pain and had more restricted postpartum physical ability than women who did not catastrophize.

LIMITATIONS

The fact that some women did not complete the questionnaire at all test occasions might have reduced the generalizability of the results.

CONCLUSIONS

The common idea that levels of catastrophizing are "stable" within personality should be reconsidered, because for 1 of 3 women, the levels of catastrophizing changed over time. A majority of women reported not catastrophizing. However, catastrophizing in relation to pregnancy seems to be associated with lumbopelvic pain and postpartum physical ability. The results indicated that the role of catastrophizing in this context should be studied further.

Development of a cumulative psychosocial factor index for problematic recovery following work-related musculoskeletal injuries

BACKGROUND

Psychosocial variables such as fear of movement, depression, and pain catastrophizing have been shown to be important prognostic factors for a wide range of pain-related outcomes. The potential for a cumulative relationship between different elevated psychosocial factors and problematic recovery following physical therapy has not been fully explored.

OBJECTIVE

The purpose of this study was to determine whether the level of risk for problematic recovery following work-related injuries is associated with the number of elevated psychosocial factors.

DESIGN

This was a prospective cohort study.

METHODS

Two hundred two individuals with subacute, work-related musculoskeletal injuries completed a 7-week physical therapy intervention and participated in testing at treatment onset and 1 year later. An index of psychosocial risk was created from measures of fear of movement, depression, and pain catastrophizing. This index was used to predict the likelihood of experiencing problematic recovery in reference to pain intensity and return-to-work status at the 1-year follow-up.

RESULTS

Logistic regression analysis revealed that the number of prognostic factors was a significant predictor of persistent pain and work disability at the 1-year follow-up. Chi-square analysis revealed that the risk for problematic recovery increased for patients with elevated levels on at least 1 psychosocial factor and was highest when patients had elevated scores on all 3 psychosocial factors.

LIMITATIONS

The physical therapy interventions used in this study were not standardized. This study did not include a specific measure for physical function.

CONCLUSIONS

The number of elevated psychosocial factors present in the subacute phase of recovery has a cumulative effect on the level of risk for problematic recovery 1 year later. This research suggests that a cumulative prognostic factor index could be used in clinical settings to improve prognostic accuracy and to facilitate clinical decision making.

The Continuing Evolution of Biopsychosocial Interventions for Chronic Pain

In the last several decades, great strides have been made in the treatment of persistent painful conditions. The scope of treatment has shifted from purely biomedical, including approaches built upon cognitive, behavioral, and social psychological principles. This article reports and discusses several key paradigm shifts that fueled this revolutionary change in the management of chronic pain. The progressive development of theoretical metamodels and treatment conceptualizations is presented. Cognitive behavioral therapy (CBT) is the most widely accepted biopsychosocial treatment for chronic pain and is founded upon a rich theoretical tradition. The CBT rationale, and empirical evidence to support its efficacy, is presented. The emergence and promise of mindfulness-based and acceptance-based interventions is also discussed. The article concludes with the assertion that future treatment outcome research should focus on understanding the treatment-specific and common factors associated with efficacy.

Pain-related fear: a critical review of the related measures

Objectives: In regards to pain-related fear, this study aimed to: (1) identify existing measures and review their measurement properties, and (2) identify the optimum measure for specific constructs of fear-avoidance, pain-related fear, fear of movement, and kinesiophobia. Design: Systematic literature search for instruments designed to measure fear of pain in patients with persistent musculoskeletal pain. Psychometric properties were evaluated by adjusted Wind criteria. Results: Five questionnaires (Fear-Avoidance Beliefs Questionnaire (FABQ), Fear-Avoidance of Pain Scale (FAPS), Fear of Pain Questionnaire (FPQ), Pain and Anxiety Symptoms Scale (PASS), and the Tampa Scale for Kinesiophobia (TSK)) were included in the review. The main findings were that for most questionnaires, there was no underlying conceptual model to support the questionnaire's construct. Psychometric properties were evaluated by diverse methods, which complicated comparisons of different versions of the same questionnaires. Construct validity and responsiveness was generally not supported and/or untested. Conclusion: The weak construct validity implies that no measure can currently identify who is fearful. The lack of evidence for responsiveness restricts the current use of the instruments to identify clinically relevant change from treatment. Finally, more theoretically driven research is needed to support the construct and thus the measurement of pain-related fear.

Application of a diagnosis-based clinical decision guide in patients with low back pain

Background

Low back pain (LBP) is common and costly. Development of accurate and efficacious methods of diagnosis and treatment has been identified as a research priority. A diagnosis-based clinical decision guide (DBCDG; previously referred to as a diagnosis-based clinical decision rule) has been proposed which attempts to provide the clinician with a systematic, evidence-based means to apply the biopsychosocial model of care. The approach is based on three questions of diagnosis. The purpose of this study is to present the prevalence of findings using the DBCDG in consecutive patients with LBP.

Methods

Demographic, diagnostic and baseline outcome measure data were gathered on a cohort of LBP patients examined by one of three examiners trained in the application of the DBCDG.

Results

Data were gathered on 264 patients. Signs of visceral disease or potentially serious illness were found in 2.7%. Centralization signs were found in 41%, lumbar and sacroiliac segmental signs in 23% and 27%, respectively and radicular signs were found in 24%. Clinically relevant myofascial signs were diagnosed in 10%. Dynamic instability was diagnosed in 63%, fear beliefs in 40%, central pain hypersensitivity in 5%, passive coping in 3% and depression in 3%.

Conclusion

The DBCDG can be applied in a busy private practice environment. Further studies are needed to investigate clinically relevant means to identify central pain hypersensitivity, poor coping and depression, correlations and patterns among the diagnostic components of the DBCDG as well as inter-examiner reliability and efficacy of treatment based on the DBCDG.

Determinants for lumbopelvic pain 6 months postpartum

PURPOSE

To evaluate potential determinants of self-reported lumbopelvic pain 6 months postpartum for pregnant women with and without lumbopelvic pain.

METHODS

Questionnaires were answered in weeks 19-21 of pregnancy and at 6 months postpartum. The Pain Catastrophizing Scale was used to assess exaggerated negative thoughts about pain experiences, the Fear-Avoidance Beliefs Questionnaire to assess beliefs about how physical activity affects back pain, the Visual Analogue Scale to assess pain intensity, the Disability Rating Index to assess physical ability, and the Nottingham Health Profile to assess health-related quality of life. A Cox proportional hazards model was used to analyse the data.

RESULTS

Of the 273 women who answered at both occasions, 112 had lumbopelvic pain in pregnancy and 161 did not. For pregnant women with lumbopelvic pain a higher level of catastrophizing and a more restricted physical ability both doubled the risk for postpartum lumbopelvic pain.

CONCLUSIONS

We conclude that catastrophizing and physical ability, in weeks 19-21 of pregnancy determine postpartum lumbopelvic pain, and hence that, women at risk might be identified by the use of a biopsychosocial approach in pregnancy. It seems important to take these results into consideration both when forming preventive strategies and in rehabilitation.

Evaluating an in-home multicomponent cognitive behavioural programme to manage concerns about falls and associated activity avoidance in frail community-dwelling older people: Design of a randomised control trial [NCT01358032]

BACKGROUND

Concerns about falls are frequently reported by older people. These concerns can have serious consequences such as an increased risk of falls and the subsequent avoidance of activities. Previous studies have shown the effectiveness of a multicomponent group programme to reduce concerns about falls. However, owing to health problems older people may not be able to attend a group programme. Therefore, we adapted the group approach to an individual in-home programme.

METHODS/DESIGN

A two-group randomised controlled trial has been developed to evaluate the in-home multicomponent cognitive behavioural programme to manage concerns about falls and associated activity avoidance in frail older people living in the community. Persons were eligible for study if they were 70 years of age or over, perceived their general health as fair or poor, had at least some concerns about falls and associated avoidance of activity. After screening for eligibility in a random sample of older people, eligible persons received a baseline assessment and were subsequently allocated to the intervention or control group. Persons assigned to the intervention group were invited to participate in the programme, while those assigned to the control group received care as usual. The programme consists of seven sessions, comprising three home visits and four telephone contacts. The sessions are aimed at instilling adaptive and realistic views about falls, as well as increasing activity and safe behaviour. An effect evaluation, a process evaluation and an economic evaluation are conducted. Follow-up measurements for the effect evaluation are carried out 5 and 12 months after the baseline measurement. The primary outcomes of the effect evaluation are concerns about falls and avoidance of activity as a result of these concerns. Other outcomes are disability and falls. The process evaluation measures: the population characteristics reached; protocol adherence by facilitators; protocol adherence by participants (engagement in exposure and homework); opinions about the programme of participants and facilitators; perceived benefits and achievements; and experienced barriers. The economic evaluation examines the impact on health-care utilisation, as well as related costs.

DISCUSSION

A total number of 389 participants is included in the study. Final results are expected in 2012.

TRIAL REGISTRATION

NCT01358032.

The effect of fear of movement beliefs on pain and disability after surgery for lumbar and cervical degenerative conditions

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

To examine differences between preoperative and postoperative fear of movement and investigate the relationship between fear of movement and pain, disability and physical health after spinal surgery for degenerative conditions.

SUMMARY OF BACKGROUND DATA

Consistent evidence supports the relationship between fear of movement and higher levels of pain and disability in various chronic pain populations. Fear of movement among patients undergoing spinal surgery for chronic pain has received little attention in the literature.

METHODS

Participants were 141 patients treated with surgery for lumbar and cervical degenerative conditions. Assessments were conducted before surgery and 6 weeks and 3 months after hospitalization. Fear of movement was measured with the Tampa Scale for Kinesiophobia and outcomes were measured with the Brief Pain Inventory, Oswestry or Neck Disability Index, and 12-Item Short Form Health Survey (SF-12).

RESULTS

Follow-up rates were 91% and 87% for 6 weeks and 3 months, respectively. Fear of movement beliefs improved after surgery, but 49% of patients continued to have high fear of movement at 6-week follow-up and 39% at 3-month follow-up. Patients with higher levels of fear of movement had poorer postoperative outcomes. Multilevel linear regression analyses found that postoperative fear of movement was independently associated with postoperative pain intensity, pain interference, disability, and physical health (P < 0.001), after controlling for depression, age, sex, education, race, comorbidities, type and area of surgery, prior surgeries, and baseline outcome score. Preoperative fear of movement was not predictive of poorer surgical outcomes.

CONCLUSION

Results demonstrate that postoperative but not preoperative fear of movement beliefs explain unique and significant variance in postoperative pain, disability, and physical health. Clinicians interested in improving surgical outcomes should address postoperative fear of movement along with other traditional clinical and medical risk factors. Recommendations include postoperative screening for high fear of movement beliefs and incorporating cognitive-behavioral techniques into postoperative rehabilitation for at-risk surgical spine patients.

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.

Factors contributing to physical activity in a chronic low back pain clinical sample: a comprehensive analysis using continuous ambulatory monitoring

Back pain is one of the most common causes of disability in industrialized nations. Despite this, the variables that contribute to disability are not well understood and optimal measurement strategies of disability have not yet been determined. The present study sought to comprehensively assess the strongest predictors of physical activity as a proxy for disability. New patients in a chronic pain specialty clinic completed questionnaires to assess the predictors of physical activity and engaged in 5 days of home data collection wearing an accelerometer to assess physical activity in daily life, which is how disability was operationalized in this study. Analysis of repeated measures patient data revealed that, of 3 composite variables each representing a theoretical model, the model representative of operant factors significantly predicted physical activity. Subsequent analyses showed that pain sensitivity, fear avoidance, and solicitous spousal responses account for a significant amount of the variance in physical activity. These findings suggest that external sources of reinforcement or punishment may serve to influence physical behavior beyond that of internal cues such as fear avoidance or pain. Implications for treatment are discussed, including the potential benefits of specifically incorporating the patient's sources of operant reinforcement or punishment into treatment.

Evaluation of the fear-avoidance model with health care workers experiencing acute/subacute pain

Studies in the literature do not show clear evidence supporting the relationship between pain and depressive symptoms in individuals experiencing acute/subacute pain compared to those experiencing chronic pain. However, more information is needed about which variables act as mediators in the pain-depression relationship in people having acute/subacute pain, before pain becomes chronic. Our objectives were to test the suitability of the fear-avoidance model in a sample of 110 health care workers experiencing acute/subacute pain using path analyses, to improve the model as needed, and to examine a model involving both pain catastrophizing and pain self-efficacy with work status as a final outcome. Overall, the results indicated that adjustments to the fear-avoidance model were required for people experiencing acute/subacute pain, in which fear-avoidance beliefs and depressive symptoms were concurrent rather than sequential. The catastrophizing concept was most closely associated with depressive symptoms, while pain self-efficacy was directly associated with fear-avoidance beliefs and indirectly to work outcomes. Assessing and modifying pain self-efficacy in acute/subacute pain patients is important for interventions aiming to decrease fear-avoidance and improve work outcomes.

Strategies Aimed at Preventing Chronic Post-surgical Pain: Comprehensive Perioperative Pain Management after Total Joint Replacement Surgery

PURPOSE

Chronic post-surgical pain (CPSP) is a frequent outcome of musculoskeletal surgery. Physiotherapists often treat patients with pain before and after musculoskeletal surgery. The purposes of this paper are (1) to raise awareness of the nature, mechanisms, and significance of CPSP; and (2) to highlight the necessity for an inter-professional team to understand and address its complexity. Using total joint replacement surgeries as a model, we provide a review of pain mechanisms and pain management strategies.

SUMMARY OF KEY POINTS

By understanding the mechanisms by which pain alters the body's normal physiological responses to surgery, clinicians selectively target pain in post-surgical patients through the use of multi-modal management strategies. Clinicians should not assume that patients receiving multiple medications have a problem with pain. Rather, the modern-day approach is to manage pain using preventive strategies, with the aims of reducing the intensity of acute postoperative pain and minimizing the development of CPSP.

CONCLUSIONS

The roles of biological, surgical, psychosocial, and patient-related risk factors in the transition to pain chronicity require further investigation if we are to better understand their relationships with pain. Measuring pain intensity and analgesic use is not sufficient. Proper evaluation and management of risk factors for CPSP require inter-professional teams to characterize a patient's experience of postoperative pain and to examine pain arising during functional activities.

Psychologically informed interventions for low back pain: an update for physical therapists

A central theme of current evidence-based guidelines for managing low back pain is endorsement of the resumption of activities despite the presence of pain. This task can be challenging for both therapists and patients, and there are many essentially psychological obstacles to implementing the guidelines. These obstacles can be overcome by knowing how to recognize potential psychological obstacles and understanding the options for managing psychological obstacles in combination with activity-based interventions. This article is intended to address these tasks by explaining and describing the application of empirically based psychological principles and strategic clinical reasoning. Importantly, the roles of skills in assessment, treatment planning, and communication with patients are identified as essential but feasible skills for physical therapists to acquire with appropriate training.

Relationship among pain catastrophizing, depressed mood, and outcomes across physical therapy treatments

BACKGROUND

Pain catastrophizing and emotional distress can act as prognostic factors for pain and disability. Research on how these variables interact within individuals and over time is in an early stage. Understanding various patterns of prognostic factors and how these factors change during treatment is important for developing treatments targeting important factors.

OBJECTIVE

The primary aim of this study was to investigate relationships between pain catastrophizing and depressed mood in people seeking primary care for musculoskeletal pain. An additional aim was to relate these patterns of prognostic factors to outcomes during a 6-month period.

DESIGN

The design was prospective; data were obtained at baseline and at follow-up.

METHODS

Forty-two physical therapists taking part in an educational program recruited, from their clinical practices in primary care, consecutive patients who were currently experiencing a pain problem. Patients received various physical therapy interventions between baseline and follow-up.

RESULTS

On the basis of patterns of scoring for pain catastrophizing and depressed mood, 4 subgroups of participants were found. Belonging to a subgroup with elevated levels of either pain catastrophizing or depressed mood at baseline was related to the absence of improvement and elevated levels of disability after physical therapy interventions. Furthermore, elevated levels of both variables were related to the highest levels of disability.

LIMITATIONS

The analyses relied on self-report. Neither treatment content nor pain-related fear was measured. The sample was a mixture of participants reporting acute pain and subacute pain.

CONCLUSIONS

The results stress the importance of assessing and targeting prognostic factors. Moreover, the results suggest the need to tailor treatments to match patterns of prognostic factors and the need to target depressed mood and pain catastrophizing in physical therapy interventions.

Effect of fear-avoidance beliefs of physical activities on a model that predicts risk-adjusted functional status outcomes in patients treated for a lumbar spine dysfunction

STUDY DESIGN

Retrospective analysis of a prospective, longitudinal cohort study of 30 858 patients being treated for a lumbar spine dysfunction in outpatient physical therapy.

OBJECTIVES

To determine effect of adding a single-item screening variable classifying patients with elevated versus not-elevated scores of fear-avoidance beliefs of physical activities at intake, on a model predicting risk-adjusted functional status (FS) outcomes.

BACKGROUND

Outcomes must be risk-adjusted before making meaningful interpretations. Elevated fear-avoidance beliefs scores have been predictive of poor outcomes. But the importance of elevated fear-avoidance scores in a multivariable model predicting FS outcomes needs further study.

METHODS

Using retrospective analyses, predictive ability (R2) of multivariable linear regression models of discharge FS with and without classification by elevated versus not-elevated fear-avoidance scores were compared, while controlling for intake FS, age, symptom acuity, surgical history, gender, number of comorbidities, and payer. Percent variance controlled and beta coefficients (95% confidence intervals) of each variable in both models were compared. A split-half design was used for model cross-validation. Predictive ratios (predicted FS, divided by actual discharge FS) were assessed.

RESULTS

Adding fear-avoidance beliefs classification to the discharge FS model improved (P<.001) model predictive ability but only slightly (R2 without, and with, fear-avoidance classification, 0.2997 and 0.3010, respectively). Variables impacted models similarly (95% confidence intervals not different). Fear-avoidance classification added 0.2% data variance control to the existing model. Cross-validation was supported. Predictive ratios were 1.09 and 1.10, without and with fear-avoidance, respectively.

CONCLUSION

Although screening for elevated fear-avoidance beliefs of physical activities significantly improves the FS outcomes predictive model, the amount of additional meaningful interpretation of FS outcomes was minimal. Exploration of other clinically relevant variables designed to improve outcomes prediction is warranted.

LEVEL OF EVIDENCE

Prognosis, level 2c.

Cross-cultural adaptation, reliability and validity of the Chinese version of the Fear Avoidance Beliefs Questionnaire

The Fear Avoidance Beliefs Questionnaire (FABQ) was translated and cross-culturally adapted for China. Its psychometric properties were then evaluated in Chinese-speaking patients with low-back pain and the scales were tested for internal consistency, reproducibility, ceiling-and-floor effects, construct validity and responsiveness. A total of 15 patients were selected for pre-testing and a further 230 patients completed the FABQ (and other scales) at baseline and 14 days later. A test-retest reliability analysis was carried out on 61 of the 230 patients. The FABQ was found to be easily understood. Explorative factor analysis by principal components analysis, yielded a two-factor model for the FABQ, relating to work and physical activity, and this was confirmed by confirmatory factor analysis using structural equation modelling. The FABQ yielded high values for internal consistency and reproducibility; no ceiling-and-floor effects were detected. Generally, the FABQ scales and baseline variables were weakly correlated. Cohen's effect size was 0.22 and responsiveness was low. It was concluded that the translation and adaptation of the FABQ into Chinese was successful; the scales had acceptable factor structure, internal consistency, test-retest reliability and construct validity.

Fear-avoidance beliefs are associated with disability in older American adults with low back pain

BACKGROUND

Although fear-avoidance beliefs (FABs) have been explored in younger adults and Spanish older adults, their relationships to measures of low back pain (LBP)-related disability, overall physical health, and falling have not been investigated in older American adults.

OBJECTIVE

The purpose of this study was to examine the association of FABs with self-reported disability, physical health, and falling among community-dwelling older adults with LBP in the United States.

DESIGN

This was a cross-sectional study.

METHODS

Ninety-three community-dwelling men and women with current LBP were included in this analysis. Participants completed the Fear-Avoidance Beliefs Questionnaire physical activity subscale (FABQ-PA). The modified Oswestry Disability Questionnaire (mOSW) and the Quebec Back Pain Disability Scale (QUE) were used to measure self-reported disability, and the Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire (SF-36) physical component summary (PCS) score was used to assess physical health. Participants provided demographic information and information regarding LBP duration and intensity. Linear regression models were developed using the following dependent variables: mOSW, QUE, and SF-36 PCS scores. Logistic regression was used to determine the association between high FABs and falling.

RESULTS

For each analysis, the FABQ-PA score independently explained 3% to 6% of the variance in the LBP-related disability score and 3% of the variance in the SF-36 PCS score. For all dependent variables, the strongest contributors to explained variance were pain intensity, assistive device use, and FABQ-PA score. High FABs were associated with falling.

LIMITATIONS

Future investigations might seek a more diversified sample and utilize both qualitative and quantitative measures for assessing disability and physical health.

CONCLUSIONS

Physical activity FABs are independently associated with self-reported disability and overall physical health in older American adults with LBP. High FABs may warrant balance and falls assessment.

Psychometric properties of a Korean version of the Pain Anxiety Symptoms Scale-20 in chronic pain patients

BACKGROUND

The Pain Anxiety Symptoms Scale (PASS-20) consists of 20 items designed to assess four aspects of pain-related anxiety: cognitive anxiety, escape-avoidance behaviors, fear of pain, and physiological symptoms of anxiety. Although the PASS-20 is a well-established measure of pain-related anxiety in Western samples, different cultures may yield a different factor structure or different associations with pain-related outcome variables.

PURPOSE

The purposes of this study were (1) to examine the factor structure of a Korean language version of the PASS-20 (KPASS-20); (2) to examine reliability and construct validity of the KPASS-20; and (3) to compare the findings of this study with those of the original psychometric study using a Western sample.

METHOD

A total of 166 patients seeking treatment in a university pain management center located in Seoul, Korea participated.

RESULTS

Results indicated that the KPASS-20 consists of three factors, "fearful thinking," "physiological response," and "avoidance," and has adequate reliability and construct validity estimates. On the mean total score of the KPASS-20, the Korean sample had a significantly higher score than the original Western sample. In addition, in correlation analyses between the total score of the KPASS-20, physical functioning, and pain severity, the Korean sample had significantly higher coefficients, whereas similar differences were not found in the analyses of psychological functioning and depression.

CONCLUSION

The findings provide preliminary support for the reliability and validity of the KPASS-20.

Concurrent measurement of isokinetic muscle strength of the trunk, knees, and ankles in patients with lumbar disc herniation with sciatica

STUDY DESIGN

A cross-sectional study comparing normal subjects and patients with lumbar disc herniation (LDH) with sciatica.

OBJECTIVE

To simultaneously measure the isokinetic muscle strength of the trunk, knees, and ankles in both groups.

SUMMARY OF BACKGROUND DATA

Coordination between the trunk and lower extremity muscles is important for normal physical activity. Reduced trunk and knee muscle strength have been reported in patients with lower level LDH; however, ankle performance in these patients is still unknown.

METHODS

We recruited 43 normal subjects as controls and 33 patients with lower level LDH with sciatica. The isokinetic strength of the trunk, knees, and ankles was measured at 2 velocities in random order: 60°/s and 120°/s, and 60°/s and 180°/s for trunk and ankle strength and for knee strength, respectively.

RESULTS

The isokinetic trunk strength was significantly lower in the LDH group irrespective of test modes or velocity. Despite unilateral sciatica or test modes and velocity, the unilateral knee strength was significantly lower in the LDH group than that in the control group. Knee extension torque was also found to be significantly lower in the limbs with sciatica than in those without sciatica at the testing velocity of 180°/s (80.25 ± 24.88 vs. 95.42 ± 26.29 Nm, P < 0.05). Irrespective of unilateral sciatica or test velocity, ankle plantar flexion torque revealed to be significantly lower in the LDH group than the control group; however, dorsiflexion torque was not different. Significant correlations were demonstrated among the total muscle strength of the trunk, knees, and ankles in both groups.

CONCLUSION

Besides the lower trunk strength, concurrent lower unilateral knee and ankle plantar flexion but not dorsiflexion strength was demonstrated in the LDH subjects with unilateral sciatica, regardless of its location. As compared to the limbs without sciatica, an additional 14% reduction of knee extension torque at 180°/s was found in the limbs with sciatica in the LDH patients.

Comparison of graded exercise and graded exposure clinical outcomes for patients with chronic low back pain

STUDY DESIGN

Quasi-experimental clinical trial.

OBJECTIVES

This study compared outcomes from graded exercise and graded exposure activity prescriptions for patients participating in a multidisciplinary rehabilitation program for chronic low back pain. Our primary purpose was to investigate whether pain and disability outcomes differed based on treatment received (graded exercise or graded exposure). Our secondary purpose was to investigate if changes in selected psychological factors were associated with pain and disability outcomes.

BACKGROUND

Behavioral interventions have been advocated for decreasing pain and disability from low back pain, yet relatively few comparative studies have been reported in the literature.

METHODS

Consecutive sample with chronic low back pain recruited over a 16-month period from an outpatient chronic pain clinic. Patients received physical therapy supplemented with either graded exercise (n=15) or graded exposure (n=18) principles. Graded exercise included general therapeutic activities and was progressed with a quota-based system. Graded exposure included specific activities that were feared due to back pain and was progressed with a hierarchical exposure paradigm. Psychological measures were pain-related fear (Fear-Avoidance Beliefs Questionnaire, Tampa Scale for Kinesiophobia, Fear of Pain Questionnaire), pain catastrophizing (Coping Strategies Questionnaire), and depressive symptoms (Beck Depression Inventory). Primary outcome measures were pain intensity (visual analog scale) and self-report of disability (modified Oswestry Disability Questionnaire).

RESULTS

Statistically significant improvements (P<.01) were observed for pain intensity and disability at discharge. The rate of improvement did not differ based on behavioral intervention received (P>.05 for these comparisons). Overall, 50% of patients met criterion for minimally important change for pain intensity, while 30% met this criterion for disability. Change in depressive symptoms was associated with change in pain intensity, while change in pain catastrophizing was associated with change in disability.

CONCLUSIONS

Physical therapy supplemented with graded exercise or graded exposure resulted in equivalent clinical outcomes for pain intensity and disability. The overall treatment effects were modest in this setting. Instead of being associated with a specific behavioral intervention, reductions in pain and disability were associated with reductions in depressive symptoms and pain catastrophizing, respectively.

LEVEL OF EVIDENCE

Therapy, level 2b–.