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

Work ability is influenced by kinesiophobia among patients with persistent pain

The purpose of this study was to investigate how kinesiophobia fluctuates in patients over a four weeks multimodal rehabilitation program and to study the relationship between work ability and kinesiophobia. The study included 112 patients (94 women, 18 men). Measurements were made before, directly after, 2 months after, and 12 months after the program. The level of work ability was rated by the patients on a scale from 0% to 100%, and kinesiophobia was measured by the Swedish version of the Tampa Scale for Kinesiophobia (TSK-SV). Kinesiophobia decreased between the start of the multimodal rehabilitation program and the follow-up periods. Work ability increased over time, but not between baseline and the 2-month follow-up. Decreases in the TSK-SV score between baseline and the 2-month follow-up were related to the increased probability of improved work ability at the 12-month follow-up. In conclusion, a decrease in kinesiophobia seems to be related to increased work ability of patients participating in a 4-week multimodal rehabilitation program.

Movement control tests for the lumbopelvic complex. Are these tests reliable and valid?

This study evaluated inter- and intra-observer reliability and discriminative validity of three movement control tests: 1) standing knee-lift test; 2) static lunge test; and 3) dynamic lunge test. Thirty-eight subjects, 21 with low-back pain and 17 healthy, were video-recorded while performing the tests. Four physical therapists scored the tests according to a standardized protocol and calculated a composite score for each test based on the number of incorrect test components. Inter-observer reliability for the composite scores ranged between 0.68 and 0.80 (ICC 2,k) and intra-observer reliability between 0.54 and0.82 (ICC 2,1). The separate test components ranged between 0.32 and 0.91 (κ_free) for inter-observer reliability and 0.42 and1.00 for intra-observer reliability. Test components showing the highest values were: back extension; arm lowering; and shoulders moving backwards. Components hip hitch, trunk lateral flexion, knee not lifted straight up and hips moving backwards did not reach accepted thresholds. Discriminative validity ranged between 0.47 and 0.56 (AUC). As our results showed an overall good agreement for the composite, scores and for the majority of the included test components the tests can be considered reliable enough. As the tests' discriminative ability was close to "none", they should, however, not be used for diagnostic purposes but should be further evaluated toward predicted validity.

The influence of pain-related beliefs on physical activity and health attitudes in patients with claudication: A pilot study

We examined how pain beliefs are related to symptom severity, expectations of risk/benefits, and baseline physical activity among claudicants. Eligible patients at the Michael E DeBakey Veterans Affairs Medical Center were administered questionnaires that measured: fear-avoidance beliefs (Fear-Avoidance Beliefs Questionnaire [FABQ]), walking impairment, baseline physical activity, claudication type, and risk/benefit attitudes. Among 20 participants, the median age was 69 years (IQR: 66–75). In our efforts to understand how fear-avoidance beliefs influenced physical activity among people with claudication, we found that 12 out of 19 participants (63%) thought that the primary etiology of their pain was walking, while 18 (out of 20) (90%) people thought that walking would exacerbate their leg symptoms – suggesting that there was some confusion regarding the effects of walking on claudication. Those who expected that walking would benefit their symptoms more than surgery reported fewer fear-avoidance beliefs ( p=0.01), but those who believed that walking would make their leg pain worse expected greater benefit from surgery ( p=0.02). As symptom severity increased, fear-avoidance beliefs also increased ( p=0.001). The association between symptom severity and fear-avoidance beliefs indicates that as pain or impairment increases, the likelihood of avoiding behaviors that are thought to cause pain might also increase. Accounting for pain-related beliefs when recommending physical activity for claudication should be considered.

Prognostic psychosocial factors for disabling low back pain in Japanese hospital workers

Background

Although the occupational health field has identified psychosocial factors as risk factors for low back pain that causes disability, the association between disabling low back pain and psychosocial factors has not been examined adequately in Japanese hospital workers. Therefore, this study examined the association between low back pain, which interfered with work, and psychosocial factors in Japanese hospital workers.

Method

This cross-sectional study was conducted at a hospital in Japan. In total, 280 hospital workers were recruited from various occupational settings. Of these, 203 completed a self-administered questionnaire that included items concerning individual characteristics, severity of low back pain, fear-avoidance beliefs (Fear-Avoidance Beliefs Questionnaire), somatic symptoms (Somatic Symptom Scale-8), psychological distress (K6), workaholism, and work-related psychosocial factors (response rate: 72.5%). Logistic regression was used to explore risk factors associated with disabling low back pain.

Results

Of the 203 participants who completed questionnaires, 36 (17.7%) reported low back pain that interfered with their work. Multivariate analyses with individual factors and occupations adjusted for showed statistically significant associations between disabling low back pain and fear-avoidance beliefs (adjusted odds ratio [OR]: 2.619, 95% confidence interval [CI]: 1.003–6.538], somatic symptoms (OR: 4.034, 95% CI: 1.819–9.337), and interpersonal stress at work (OR: 2.619, 95% CI: 1.067–6.224).

Conclusions

Psychosocial factors, such as fear-avoidance beliefs, somatic symptoms, and interpersonal relationships at work, were important risk factors in low back pain that interfered with work in Japanese hospital workers. With respect to occupational health, consideration of psychosocial factors is required to reduce disability related to low back pain.

Cross-cultural adaptation, reliability and construct validity of the Tampa scale for kinesiophobia for temporomandibular disorders (TSK/TMD-Br) into Brazilian Portuguese

Fear of movement (kinesiophobia) seems to play an important role in the development of chronic pain. However, for temporomandibular disorders (TMD), there is a scarcity of studies about this topic. The Tampa Scale for Kinesiophobia for TMD (TSK/TMD) is the most widely used instrument to measure fear of movement and it is not available in Brazilian Portuguese. The purpose of this study was to culturally adapt the TSK/TMD to Brazilian Portuguese and to assess its psychometric properties regarding internal consistency, reliability, and construct and structural validity. A total of 100 female patients with chronic TMD participated in the validation process of the TSK/TMD-Br. The intraclass correlation coefficient (ICC) was used for statistical analysis of reliability (test-retest), Cronbach's alpha for internal consistency, Spearman's rank correlation for construct validity and confirmatory factor analysis (CFA) for structural validity. CFA endorsed the pre-specified model with two domains and 12-items (Activity Avoidance - AA/Somatic Focus - SF) and all items obtained a loading factor greater than 0·4. Acceptable levels of reliability were found (ICC > 0·75) for all questions and domains of the TSK/TMD-Br. For internal consistency, Cronbach's α of 0·78 for both domains were found. Moderate correlations (0·40 < r < 0.60) were observed for 84% of the analyses conducted between TSK/TMD-Br scores versus catastrophising, depression and jaw functional limitation. TSK/TMD-Br 12 items and two-factor demonstrated sound psychometric properties (transcultural validity, reliability, internal consistency and structural validity). In such a way, the instrument can be used in clinical settings and for research purposes.

The impact of pain-related fear on neural pathways of pain modulation in chronic low back pain

Supplemental Digital Content is Available in the Text.

Introduction:

Pain-related fear plays a substantial role in chronic low back pain (LBP) by amplifying the experienced disability. Related dysfunctional emotions and cognitions may also affect sensory aspects of pain through a modulatory pathway in which the periaqueductal gray (PAG) and the amygdala play key roles.

Objectives:

We therefore hypothesized a differential amygdala-PAG functional connectivity (FC) in patients with chronic LBP that is modulated by the degree of pain-related fear.

Methods:

We used data of a previously reported fMRI study where 20 chronic LBP patients (7 females, mean age = 39.35) and 20 healthy controls (12 females, mean age = 32.10) were asked to observe video clips showing potentially harmful and neutral activities for the back. Pain-related fear was assessed using the Tampa Scale of kinesiophobia (TSK) and Fear Avoidance Beliefs questionnaires (FABQ). Generalized psychophysiological interactions were used to reveal task-based FC.

Results:

Compared to controls, patients exhibited a significant decrease in amygdala-PAG-FC (P = 0.022) during observation of harmful activities, but not of neutral activities. Furthermore, amygdala-PAG-FC correlated negatively with Tampa Scale of kinesiophobia scores in patients (R² = 0.28, P = 0.01) but not with Fear Avoidance Beliefs questionnaires scores.

Discussion:

Our findings might indicate a maladaptive psychobiological interaction in chronic LBP patients characterized by a disrupted amygdala-PAG-FC that is modulated by the degree of pain-related fear. These results shed new light on brain mechanisms underlying psychological factors that may have pronociceptive effects in chronic LBP.

The Influence of Pre- and Postoperative Fear Avoidance Beliefs on Postoperative Pain and Disability in Patients With Lumbar Spinal Stenosis: Analysis of the Lumbar Spinal Outcome Study (LSOS) Data

STUDY DESIGN

Prospective multicenter cohort study.

OBJECTIVE

To evaluate the effect of pre- and postoperatively assessed fear avoidance beliefs (FAB) on pain and disability in patients with degenerative lumbar spinal stenosis (LSS) after decompression surgery.

SUMMARY OF BACKGROUND DATA

To the present, the influence of pre- and postoperative FAB on the prognosis after surgery for LLS is still unclear.

METHODS

Patients of the Swiss Lumbar Stenosis Outcome Study (LSOS) with confirmed LSS undergoing first-time decompression without fusion were enrolled in this study. The main outcome of this study was minimal clinically important difference (MCID) in spinal stenosis measure symptoms (pain) and function (disability) after 12 months. To analyze the influence of pre- and postoperatively assessed FAB on pain and disability we built simple and multiple logistic regression models.

RESULTS

In this analysis of 234 patients undergoing decompression surgery for symptomatic degenerative LSS we found baseline FAB measured by the FAB physical activity subscale (FABQ-P) not to be associated with pain (OR 0.95; 95% CI: 0.55-1.67) and disability (OR 1.11; 95% CI: 0.64-1.92) at 12 months' follow-up. In the final multiple logistic regression models patients with high FABQ-P at 6 months (OR 0.46; 95% CI: 0.24-0.91) and high persistent FABQ-P at baseline and 6 months (OR 0.34, 95% CI: 0.16-0.73) were less likely to report a MCID for spinal stenosis measure symptoms at 12 months. Our analysis found a similar trend for disability; however, the results were not statistically significant.

CONCLUSION

In elderly patients undergoing decompression surgery for symptomatic degenerative LSS preoperative fear avoidance beliefs were not a prognostic indicator for the outcome. Patients with FAB at 6 months and persistent FAB were less likely to experience clinically relevant improvement in pain at 12 months. Studies should address the importance of persistent postoperative FAB.

LEVEL OF EVIDENCE

3.

People's beliefs about the meaning of crepitus in patellofemoral pain and the impact of these beliefs on their behaviour: A qualitative study

BACKGROUND

A feature of patellofemoral pain is joint crepitus. Several causes of crepitus have been described, but previous research has focused on the pathological meaning of crepitus. No research has demonstrated a definitive link between noise and pathology and its importance and meaning to patients is unresearched.

OBJECTIVE

To explore the beliefs of patients with non-osteoarthritic patellofemoral pain regarding their crepitus, and how this impacts on their behaviour.

DESIGN

Qualitative design using semi-structured interviews.

METHOD

A general inductive approach was used as this is a previously unresearched topic. Underpinned by the health beliefs model, an interview schedule was used to reflect different elements. Inductive thematic analysis was used to generate themes to represent the dataset. Participants were 11 patients diagnosed with non-osteoarthritic patellofemoral pain, crepitus as one of their symptoms, referred to an outpatient clinic.

RESULTS/FINDINGS

Three key themes emerged all with sub-themes within them. Firstly, belief about the noise had a sub-theme of search for and perceived meaning of noise. Symbolising ageing was another sub-theme whereby participants described feelings of premature ageing. The final sub-theme was emotional response with participants feeling a range of negative emotions. The second theme of the influence of others reveals participants describing two distinctly different relationships, one with friends and family and one with professionals. The final theme was avoiding the noise. A sub-theme of altering movement shows participants describing fear-avoidant behaviour.

CONCLUSION

Crepitus is a poorly understood symptom that creates negative emotions, inaccurate etiological beliefs and ultimately leads to altered behaviour.

Physical Therapy for Musculoskeletal Disorders of Workers: Role of Physical Therapists in Occupational Health

Musculoskeletal disorders in workers decrease the productivity of companies and result in socioeconomic losses. Low back pain accounted for approximately 60% of occupational diseases in the past and this is still true at present, making it a major occupational health problem in Japan. Herein, the findings about low back pain are explained as follows: the correlation between imaging examination findings and low back pain is low; psychosocial factors are involved in the onset of low back pain and how it becomes chronic; and improvement of activity is more useful than rest. Furthermore, the advantages of employing physical therapists for improving occupational health are as follows: they can 1) evaluate and intervene ergonomically; 2) provide instructions using a behavioral modification technique based on psychosocial factors; and 3) provide instructions regarding exercise programs considering obstacles to the development of a good exercise habit (painful diseases including osteoarthritis and other diseases such as hypertension and diabetes). In addition, falling, whose incidence has recently been increasing and is an important issue in occupational health, is examined from the aspect of musculoskeletal disorders. The following activities of physical therapists are introduced: the items to be checked during a tour of inspection of a workplace and detailed descriptions of work management and working environment management measures. Physical therapists are rarely involved in studies of low back pain and falling, but their knowledge and skills have been demonstrated to contribute to improving occupational health.

Is there an association between fear avoidance beliefs, and pain and disability in patients with orofacial pain?

Numerous psychosocial factors have been shown to contribute to the development and perpetuation of orofacial pain. One well-recognized model for explaining the link between psychosocial factors and chronic pain is the fear avoidance model. To date, this proposed link has not been studied in subjects with orofacial pain. During the initial evaluation of subjects with orofacial pain, we collected data on fear avoidance beliefs using the Fear Avoidance Beliefs Questionnaire, and disability and pain. At between 6 and 8 weeks follow-up, we re-collected these data, as well as data addressing subjects' perceived change in their condition. Data were analyzed using correlation coefficients and linear regression. Fear avoidance beliefs at intake were inversely correlated with intake disability, There were no significant associations between fear avoidance beliefs at initial evaluation or in changes in fear avoidance beliefs during the 6-8 weeks follow-up period; and changes in disability, pain or perceived change in condition at 6-8 weeks follow-up. Of note, fear avoidance beliefs increased over the follow-up period, despite improvements in all outcome measures. There was insufficient evidence to suggest that high levels of fear avoidance beliefs at initial evaluation are associated with higher levels of disability or pain at intake, or with change in disability, pain or perceived change in condition at 6-8 weeks follow-up. Similarly, there was insufficient evidence to suggest that changes in fear avoidance beliefs during treatment are associated with any of these outcome measures.

Outcomes of Patients With Acute Low Back Pain Stratified by the STarT Back Screening Tool: Secondary Analysis of a Randomized Trial

BACKGROUND

The impact of physical therapy on the outcomes of patients with acute low back pain (LBP) stratified by the STart Back Screening Tool (SBST) is unclear.

OBJECTIVE

The purpose of this study was to compare the outcomes of patients with acute LBP who were stratified as medium or high risk.

DESIGN

This was a secondary analysis of a randomized trial.

SETTING

Patients were recruited between March 2011 and November 2013 from primary care clinics in Salt Lake City, Utah.

PARTICIPANTS

One hundred eighty-one participants with acute LBP who were stratified as medium risk (n = 120) or high risk (n = 61) by the SBST were included. They were aged 18 through 60 years, with duration of symptoms less than 16 days, no symptoms below the knee, no treatment for LBP in the past 6 months, and an Oswestry Disability Index (ODI) score of 20% or greater.

INTERVENTION

After participants received education on how to manage their LBP, they were randomized to receive usual care (n = 97) by their primary care provider or early intervention (n = 84) by a physical therapist.

MEASUREMENTS

The primary (3-month ODI score) outcome measure was obtained at baseline and at 4 weeks, 3 months, and 1 year.

RESULTS

No differences were detected in the effect of intervention between participants stratified as medium or high risk. For the high-risk subgroup, there was a significant difference between the early intervention and usual care groups for the 3-month ODI (mean difference = -5.87 [95% CI = -11.24, -0.50]) favoring early intervention.

LIMITATIONS

The primary study was not designed to examine the SBST.

CONCLUSIONS

Patients with acute LBP stratified as high risk seem likely to respond well to one session of education. They may experience additional benefit by 3 months from evidence-based physical therapy treatments. These effects disappear at 1 year.

Increasing Recreational Physical Activity in Patients With Chronic Low Back Pain: A Pragmatic Controlled Clinical Trial

Study Design Prospective, pragmatic, nonrandomized controlled clinical trial. Background Clinical guidelines recommend physical activity for the treatment of chronic low back pain. But engaging patients in physical activity has proven difficult. Known obstacles to physical activity include low self-efficacy and fear avoidance. Objectives This study tested the effectiveness of an enhanced transtheoretical model intervention (ETMI) aimed at increasing recreational physical activity in patients with chronic low back pain, in comparison to usual physical therapy. Methods Patients (n = 220) referred to physical therapy for chronic low back pain were allocated to ETMI or to a control group. The ETMI was delivered by physical therapists and based on behavior-change principles, combined with increased reassurance, therapeutic alliance, and exposure to reduce fear avoidance. The primary outcome was back pain-related disability (Roland-Morris Disability Questionnaire). Secondary outcomes included pain intensity, mental and physical health, and levels of physical activity. Results Intention-to-treat analysis in 189 patients at 12 months indicated that patients in the ETMI group had significantly lower disability compared to usual physical therapy. The difference in mean change from baseline between the interventions was 2.7 points (95% confidence interval: 0.9, 4.5) on the Roland-Morris Disability Questionnaire. At 12 months, worst pain, physical activity, and physical health were all significantly better in patients receiving ETMI. The average number of sessions was 3.5 for the ETMI group and 5.1 for controls. Conclusion Targeting obstacles to physical activity with an intervention that includes components to address self-efficacy and fear avoidance appears to be more effective than usual physical therapy care in reducing long-term disability. Further research is needed to explore the mechanisms that impact outcomes in this intervention package. Level of Evidence Therapy, level 2b. Registered June 7, 2012 at ClinicalTrials.gov (NCT01631344). J Orthop Sports Phys Ther 2017;47(2):57-66. doi:10.2519/jospt.2017.7057.

Construct and discriminant validity of STarT Back Screening Tool - Brazilian version

•

SBST-Brazil showed a moderate to good correlation with disability tools.

•

SBST-Brazil demonstrated weak correlations with fear-avoidance beliefs.

•

SBST-Brazil discriminates LBP patients with disability and fear-avoidance beliefs.

Background

The STarT Back Screening Tool (SBST) was developed to stratify low back pain patients according to their risk of future physical disability so that prognostic subgroups can receive matched treatments in primary care.

Objective

To measure the construct and discriminative validity of the SBST-Brazil questionnaire.

Method

A hundred and fifty one patients were recruited to test the construct and discriminative validity comparing the SBST-Brazil to the Brazilian Version of the Oswestry Disability Index (ODI), Roland Morris Disability Questionnaire (RMDQ) and Fear-Avoidance Beliefs Questionnaire-Work (FABQ-W) and Physical Activity (FABQ-PA) subscales at baseline. Spearman's rank-order correlation and area under the curve (AUC) derived from receiver operating curves (ROC) for total scores and psychosocial subscale score of the SBST-Brazil were used for construct and discriminant validity analysis, respectively.

Results

The SBST-Brazil total and psychosocial subscale scores had good and moderate correlation with ODI (r = 0.61; r = 0.56, respectively) and good with RMDQ (r = 0.70; r = 0.64, respectively). Both scores of the SBST-Brazil total and psychosocial subscale correlated weakly and moderately with the FABQ-PA (r = 0.28; r = 0.34, respectively) and weakly with the FABQ-W (r = 0.18; r = 0.20, respectively). The discriminant validity with AUCs for the total and psychosocial subscale scores against reference standard ranged from 0.66 for kinesiophobia to 0.88 for disability.

Conclusion

The SBST-Brazil showed a moderate to good correlation with the disability tools, but a weak correlation with fear-avoidance beliefs. The results of discriminant validity suggest that SBST-Brazil is able to discriminate low back pain patients with disability and fear-avoidance beliefs.

Fear-avoidance beliefs are independently associated with the prevalence of chronic pain in Japanese workers

PURPOSE

Pain is a global public health problem with implications for both personal and social heath. Fear-avoidance beliefs (FABs) have been demonstrated to negatively impact and prolong pain in many Western countries, but little is known about the association between FABs and chronic pain (CP) in Asian countries, including Japan. We examined the relationship between FABs and CP in Japanese white-collar workers, a growing population with a high prevalence of CP.

METHODS

Questionnaires and company records were used to gather data from 433 Japanese white-collar workers. Data were related to experience of pain, participant sociodemographic/health/lifestyle characteristics, fear-avoidance beliefs [Tampa Scale for Kinesiophobia (TSK)], work-related psychosocial factors (Brief Job Stress Questionnaire), and depressive illness [Psychological Distress Scale (K6)]. Analysis of covariance and multilevel logistic regression modeling were used to analyze associations between the data while controlling for factors known to influence CP prevalence.

RESULTS

Prevalence rate of CP was 11.1% (48 of 433 persons). Adjusted odds ratios for participants with CP significantly increased in participants with high TSK scores, even after adjusting for factors known to influence CP prevalence.

CONCLUSION

We found a significant association between high TSK scores and CP in Japanese white-collar workers when controlling for other known factors that influence CP such as work-related psychosocial characteristics and depressive conditions. This finding suggests that FABs are independently associated with prevalence of CP.

Optimism Moderates the Influence of Pain Catastrophizing on Shoulder Pain Outcome: A Longitudinal Analysis

Study Design Secondary analysis of prospectively collected data. Background An abundance of evidence has highlighted the influence of pain catastrophizing and fear avoidance on clinical outcomes. Less is known about the interaction of positive psychological resources with these pain-associated distress factors. Objective To assess whether optimism moderates the influence of pain catastrophizing and fear avoidance on 3-month clinical outcomes in patients with shoulder pain. Methods Data from 63 individuals with shoulder pain (mean ± SD age, 38.8 ± 14.9 years; 30 female) were examined. Demographic, psychological, and clinical characteristics were obtained at baseline. Validated measures were used to assess optimism (Life Orientation Test-Revised), pain catastrophizing (Pain Catastrophizing Scale), fear avoidance (Fear-Avoidance Beliefs Questionnaire physical activity subscale), shoulder pain intensity (Brief Pain Inventory), and shoulder function (Pennsylvania Shoulder Score function subscale). Shoulder pain and function were reassessed at 3 months. Regression models assessed the influence of (1) pain catastrophizing and optimism and (2) fear avoidance and optimism. The final multivariable models controlled for factors of age, sex, education, and baseline scores, and included 3-month pain intensity and function as separate dependent variables. Results Shoulder pain (mean difference, -1.6; 95% confidence interval [CI]: -2.1, -1.2) and function (mean difference, 2.4; 95% CI: 0.3, 4.4) improved over 3 months. In multivariable analyses, there was an interaction between pain catastrophizing and optimism (β = 0.19; 95% CI: 0.02, 0.35) for predicting 3-month shoulder function (F = 16.8, R² = 0.69, P<.001), but not pain (P = .213). Further examination of the interaction with the Johnson-Neyman technique showed that higher levels of optimism lessened the influence of pain catastrophizing on function. There was no evidence of significant moderation of fear-avoidance beliefs for 3-month shoulder pain (P = .090) or function (P = .092). Conclusion Optimism decreased the negative influence of pain catastrophizing on shoulder function, but not pain intensity. Optimism did not alter the influence of fear-avoidance beliefs on these outcomes. Level of Evidence Prognosis, level 2b. J Orthop Sports Phys Ther 2017;47(1):21-30. Epub 5 Nov 2016. doi:10.2519/jospt.2017.7068.

Fear-avoidance beliefs increase perception of pain and disability in Mexicans with chronic low back pain

BACKGROUND

Fear-avoidance beliefs are related to the prognosis of chronicity in low back pain in subacute stages, however in chronic pain, is no clear the influence of these factors; it has been suggested that the study population can determine the magnitude of influence on disability and pain of those suffering from back pain. Currently, information does not exist in the Mexican population.

OBJECTIVE

To analyze the relationship between fear-avoidance beliefs with pain and disability in Mexicans with chronic low back pain; analyze potentials differences between subgroups according to the time of evolution.

METHODS

Cross-sectional study in Mexicans with chronic LBP aged between 18 and 45. Data were collected on general socio demographic characteristics, time of evolution, body mass index, pain, disability and fear-avoidance beliefs.

RESULTS

33 men and 47 women, with an average age of 34.19±7.65 years. Higher scores of fear-avoidance beliefs were obtained in women (47.2±20.99 versus 38.5±9.7; p=0.05) and single participants (p=0.04). A positive correlation was found between disability (r=0.603, p<0.001) and pain (r=0.234, p=0.03) with high scores of fear-avoidance beliefs. Through generalized linear models for disability, total score of the fear avoidance beliefs questionnaire showed a standardized beta coefficient of 0.603, p<0.001 (R² of 0.656); for pain showed a standardized beta coefficient of 0.29, p=0.01 (R² of 0.721).

CONCLUSION

The present study suggests that there is a strong relationship between pain severity, FABQ scores, and functional disability in Mexicans with chronic LBP.

Longitudinal Assessment of Self-Reported Recent Back Pain and Combat Deployment in the Millennium Cohort Study

STUDY DESIGN

A prospective cohort study.

OBJECTIVE

Activities performed during military operations vary in complexity and physical demand. The risk for mental illness following military combat deployment has been well documented. However, information regarding the possible contribution of back pain to decreased mental and functional health is scarce. To our knowledge, this is the first study to prospectively assess deployment and self-reported recent back pain in a population-based U.S. military cohort.

SUMMARY OF BACKGROUND DATA

The study consisted of Millennium Cohort participants who were followed for the development of back pain for an average of 3.9 years.

METHODS

Descriptive statistics and longitudinal analyses were used to assess the temporal relationship of deployment with self-reported recent back pain at follow-up (N = 53,933).

RESULTS

Recent back pain was self-reported by 8379 (15.5%) participants at follow-up. After adjusting for covariates, deployers with combat experiences had higher odds [odds ratio (OR) = 1.38, 95% confidence interval (95% CI): 1.28-1.50] of recent back pain than noncombat deployers. There was no association between recent back pain and nondeployers compared with noncombat deployers. Service support/supply handlers were at an increased odds of reporting recent back pain (OR = 1.11, 95% CI: 1.02-1.21) than functional support/administration occupations. Occupations associated with a physically demanding work environment had a higher risk of back pain.

CONCLUSION

Deployers with combat experiences were more likely to report back pain postdeployment. This well-defined group of military personnel may potentially benefit from integrated prevention efforts.

LEVEL OF EVIDENCE

3.

Pain-related fear and functional recovery in sciatica: results from a 2-year observational study

OBJECTIVES

The purpose of this study was to explore the associations between pain-related fear, pain disability, and self-perceived recovery among patients with sciatica and disk herniation followed up for 2 years.

PATIENTS AND METHODS

Pain-related fear was measured by the Tampa Scale for Kinesiophobia (TSK) and the Fear-Avoidance Beliefs Questionnaire-Physical Activity (FABQ-PA) subscale. Disability was measured by the Maine-Seattle Back Questionnaire. At 2 years, patients reported their sciatica/back problem on a global change scale ranging from completely gone to much worse. No specific interventions regarding pain-related fear were provided.

RESULTS

Complete data were obtained for 372 patients. During follow-up, most patients improved. In those who at 2 years were fully recovered (n=66), pain-related fear decreased substantially. In those who did not improve (n=50), pain-related fear remained high. Baseline levels of pain-related fear did not differ significantly between those who were fully recovered and the rest of the cohort. In the total cohort, the correlation coefficients between the 0-2-year change in disability and the changes in the TSK and the FABQ-PA were 0.33 and 0.38, respectively. In the adjusted regression models, the 0-2-year change in pain-related disability explained 15% of the variance in the change in both questionnaires.

CONCLUSION

Pain-related fear decreased substantially in patients who recovered from sciatica and remained high in those who did not improve. Generally, the TSK and the FABQ-PA yielded similar results. To our knowledge, this is the first study that has assessed pain-related fear in patients who recover from sciatica.

Associations between psychological factors and the effect of home-based physical exercise in women with chronic neck and shoulder pain

BACKGROUND

Exercise is often used in the treatment of chronic neck and shoulder muscle pain. It is likely that psychological aspects have an impact on the results of exercise-based treatments.

OBJECTIVES

(1) To examine the associations between psychological factors and the effect of a home-based physical exercise intervention. (2) To examine differences in psychological factors at baseline between (a) subjects who continued in the trial and those who did not and (b) subjects who completed the intervention and those who did not.

METHOD

A total of 57 women with chronic neck and shoulder pain were included in a home-based exercise intervention trial. Pain intensity, disability, and psychological factors (anxiety and depression symptoms, catastrophizing, fear-avoidance beliefs, self-efficacy, and pain acceptance) were measured at baseline, after 4-6 months, and after 1 year of exercise. Associations between the psychological factors and changes in pain intensity and disability were analysed, as well as differences in psychological factors at baseline between subjects who continued in and completed the intervention, and those who did not.

RESULTS

Associations between positive changes in pain intensity and disability were found for low fear-avoidance beliefs and low-pain self-efficacy at baseline. In addition, fear-avoidance beliefs at baseline were higher in the subjects who dropped out of the intervention than in those who continued. Pain acceptance at baseline was higher in the subjects who completed the intervention at the end of the trial.

CONCLUSION

Particularly, fear-avoidance beliefs and pain self-efficacy should be taken into consideration when implementing home-based physical exercise as treatment for chronic neck pain. In addition, high pain acceptance might improve the adherence to prescribed exercise.

The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain

The recently proposed Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)-American Pain Society (APS) Pain Taxonomy (AAPT) provides an evidence-based, multidimensional, chronic pain classification system. Psychosocial factors play a crucial role within several dimensions of the taxonomy. In this article, we discuss the evaluation of psychosocial factors that influence the diagnosis and trajectory of chronic pain disorders. We review studies in individuals with a variety of persistent pain conditions, and describe evidence that psychosocial variables play key roles in conferring risk for the development of pain, in shaping long-term pain-related adjustment, and in modulating pain treatment outcomes. We consider "general" psychosocial variables such as negative affect, childhood trauma, and social support, as well as "pain-specific" psychosocial variables that include pain-related catastrophizing, self-efficacy for managing pain, and pain-related coping. Collectively, the complexity and profound variability in chronic pain highlights the need to better understand the multidimensional array of interacting forces that determine the trajectory of chronic pain conditions.

PERSPECTIVE

The AAPT is an evidence-based chronic pain classification system in which psychosocial concepts and processes are essential in understanding the development of chronic pain and its effects. In this article we review psychosocial processes that influence the onset, exacerbation, and maintenance of chronic pain disorders.

Negative beliefs about low back pain are associated with persistent high intensity low back pain

While previous cross-sectional studies have found that negative beliefs about low back pain are associated with pain intensity, the relationship between back beliefs and persistent low back pain is not well understood. This cohort study aimed to examine the role of back beliefs in persistent low back pain in community-based individuals. A hundred and ninety-two participants from a previous musculoskeletal health study were invited to take part in a two-year follow-up study. Beliefs about back pain were assessed by the Back Beliefs Questionnaire (BBQ) at baseline and low back pain intensity was measured by the Chronic Pain Grade Questionnaire at baseline and follow-up. Of the 150 respondents (78.1%), 16 (10.7%) reported persistent high intensity low back pain, 12 (8.0%) developed high intensity low back pain, in 16 (10.7%) their high intensity low back pain resolved and 106 (70.7%) experienced no high intensity low back pain. While participants were generally positive about low back pain (BBQ mean (SD) = 30.2 (6.4)), those with persistent high intensity pain reported greater negativity (BBQ mean (SD) = 22.6 (4.9)). Negative beliefs about back pain were associated with persistent high intensity low back pain after adjusting for confounders (M (SE) = 23.5 (1.6) vs. >30.1 (1.7), p < .001). This study found negative back beliefs were associated with persistent high intensity low back pain over 2 years in community-based individuals. While further longitudinal studies are required, these findings suggest that targeting beliefs in programs designed to treat and prevent persistent high intensity low back pain may be important.

Ten weeks of physical-cognitive-mindfulness training reduces fear-avoidance beliefs about work-related activity: Randomized controlled trial

People with chronic musculoskeletal pain often experience pain-related fear of movement and avoidance behavior. The Fear-Avoidance model proposes a possible mechanism at least partly explaining the development and maintenance of chronic pain. People who interpret pain during movement as being potentially harmful to the organism may initiate a vicious behavioral cycle by generating pain-related fear of movement accompanied by avoidance behavior and hyper-vigilance.This study investigates whether an individually adapted multifactorial approach comprised of biopsychosocial elements, with a focus on physical exercise, mindfulness, and education on pain and behavior, can decrease work-related fear-avoidance beliefs.As part of a large scale 10-week worksite randomized controlled intervention trial focusing on company initiatives to combat work-related musculoskeletal pain and stress, we evaluated fear-avoidance behavior in 112 female laboratory technicians with chronic neck, shoulder, upper back, lower back, elbow, and hand/wrist pain using the Fear-Avoidance Beliefs Questionnaire at baseline, before group allocation, and again at the post intervention follow-up 10 weeks later.A significant group by time interaction was observed (P < 0.05) for work-related fear-avoidance beliefs. The between-group difference at follow-up was -2.2 (-4.0 to -0.5), corresponding to a small to medium effect size (Cohen's d = 0.30).Our study shows that work-related, but not leisure time activity-related, fear-avoidance beliefs, as assessed by the Fear-avoidance Beliefs Questionnaire, can be significantly reduced by 10 weeks of physical-cognitive-mindfulness training in female laboratory technicians with chronic pain.

Neural Correlates of Fear of Movement in Patients with Chronic Low Back Pain vs. Pain-Free Individuals

Fear of movement (FOM) can be acquired by a direct aversive experience such as pain or by social learning through observation and instruction. Excessive FOM results in heightened disability and is an obstacle for recovery from acute, subacute, and chronic low back pain (cLBP). FOM has further been identified as a significant explanatory factor in the Fear Avoidance (FA) model of cLBP that describes how individuals experiencing acute back pain may become trapped into a vicious circle of chronic disability and suffering. Despite a wealth of evidence emphasizing the importance of FOM in cLBP, to date, no related neural correlates in patients were found and this therefore has initiated a debate about the precise contribution of fear in the FA model. In the current fMRI study, we applied a novel approach encompassing: (1) video clips of potentially harmful activities for the back as FOM inducing stimuli; and (2) the assessment of FOM in both, cLBP patients (N = 20) and age- and gender-matched pain-free subjects (N = 20). Derived from the FA model, we hypothesized that FOM differentially affects brain regions involved in fear processing in patients with cLBP compared to pain-free individuals due to the recurrent pain and subsequent avoidance behavior. The results of the whole brain voxel-wise regression analysis revealed that: (1) FOM positively correlated with brain activity in fear-related brain regions such as the amygdala and the insula; and (2) differential effects of FOM between patients with cLBP and pain-free subjects were found in the extended amygdala and in its connectivity to the anterior insula. Current findings support the FOM component of the FA model in cLBP.

A value proposition for early physical therapist management of neck pain: a retrospective cohort analysis

BACKGROUND

Neck pain is one of the most common reasons for entry into the healthcare system. Recent increases in healthcare utilization and medical costs have not correlated with improvements in health. Therefore there is a need to identify management strategies for neck pain that are effective for the patient, cost efficient for the payer and provided at the optimal time during an episode of neck pain.

METHODS

One thousand five hundred thirty-one patients who underwent physical therapist management with a primary complaint of non-specific neck pain from January 1, 2008 to December 31, 2012 were identified from the Rehabilitation Outcomes Management System (ROMS) database at Intermountain Healthcare. Patients reporting duration of symptoms less than 4 weeks were designated as undergoing "early" management and patients with duration of symptoms greater than 4 weeks were designated as receiving "delayed" management. These groups were compared using binary logistic regression to examine odds of achieving Minimal Clinically Important Difference (MCID) on the Neck Disability Index (NDI) and Numerical Pain Rating Scale (NPRS). Separate generalized linear modeling examined the effect of timing of physical therapist management on the metrics of value and efficiency.

RESULTS

Patients who received early physical therapist management had increased odds of achieving MCID on the NDI (aOR = 2.01, 95 % CI 1.57, 2.56) and MCID on the NPRS (aOR = 1.82, 95 % CI 1.42, 2.38), when compared to patients receiving delayed management. Patients who received early management demonstrated the greatest value in decreasing disability with a 2.27 percentage point change in NDI score per 100 dollars, best value in decreasing pain with a 0.38 point change on the NPRS per 100 dollars. Finally, patients receiving early management were managed more efficiently with a 3.44 percentage point change in NDI score per visit and 0.57 point change in NPRS score per visit.

CONCLUSIONS

These findings suggest that healthcare systems that provide pathways for patients to receive early physical therapist management of neck pain may realize improved patient outcomes, greater value and higher efficiency in decreasing disability and pain compared to delayed management. Further research is needed to confirm this assertion.

Listening is therapy: Patient interviewing from a pain science perspective

The interview of a patient attending physical therapy is the cornerstone of the physical examination, diagnosis, plan of care, prognosis, and overall efficacy of the therapeutic experience. A thorough, skilled interview drives the objective tests and measures chosen, as well as provides context for the interpretation of those tests and measures, during the physical examination. Information from the interview powerfully influences the treatment modalities chosen by the physical therapist (PT) and thus also impacts the overall outcome and prognosis of the therapy sessions. Traditional physical therapy focuses heavily on biomedical information to educate people about their pain, and this predominant model focusing on anatomy, biomechanics, and pathoanatomy permeates the interview and physical examination. Although this model may have a significant effect on people with acute, sub-acute or postoperative pain, this type of examination may not only gather insufficient information regarding the pain experience and suffering, but negatively impact a patient's pain experience. In recent years, physical therapy treatment for pain has increasingly focused on pain science education, with increasing evidence of pain science education positively affecting pain, disability, pain catastrophization, movement limitations, and overall healthcare cost. In line with the ever-increasing focus of pain science in physical therapy, it is time for the examination, both subjective and objective, to embrace a biopsychosocial approach beyond the realm of only a biomedical approach. A patient interview is far more than "just" collecting information. It also is a critical component to establishing an alliance with a patient and a fundamental first step in therapeutic neuroscience education (TNE) for patients in pain. This article highlights the interview process focusing on a pain science perspective as it relates to screening patients, establishing psychosocial barriers to improvement, and pain mechanism assessment.

Psychological risk factors in back pain patients at an orthopaedic outpatient clinic

BACKGROUND

Psychological risk factors have shown to be important prognostic indicators of back surgery outcome. Prevalence of these risk factors has rarely been examined in an outpatient clinic population. Furthermore, it is unclear to which extent they play a role, in absence of routinely used psychological screening tools, in treatment assignment.

OBJECTIVE

First aim of this study was to examine the prevalence of psychological risk factors in back pain patients at an orthopaedic outpatient clinic. Second aim was to investigate the prognostic value of these identified risk factors in treatment assignment by the orthopaedic surgeons (conservative vs. surgery).

METHODS

Sixty-six adult back pain patients were included. Psychological risk factor prevalence was determined with the Hospital Anxiety and Depression Scale, Tampa Scale of Kinesiophobia and Pain Catastrophizing Scale. Prognostic value of these risk factors in treatment assignment was examined using statistics.

RESULTS

Respectively, 30 (45% HADS Anxiety), 27 (41%, HADS Depression), 19 (29%, PCS) and 37 (56%, TSK) patients scored above cut-off. No prognostic value of risk factors in treatment assignment, was found.

CONCLUSIONS

The majority of patients in our study is at risk of poor surgical outcome due to presence of psychological risk factors. Future studies should target the development of screening tools for an early identification of those at risk.

Subjective health complaints, functional ability, fear avoidance beliefs, and days on sickness benefits after work rehabilitation - a mediation model

Background

Long-term sick leave and withdrawal from working life is a concern in western countries. In Norway, comprehensive inpatient work rehabilitation may be offered to sick listed individuals at risk of long-term absence from work. Knowledge about prognostic factors for work outcomes after long-term sick leave and work rehabilitation is still limited. The aim of this study was to test a mediation model for various hypothesized biopsychosocial predictors of continued sick leave after inpatient work rehabilitation.

Methods

One thousand one hundred fifty-five participants on long-term sick leave from eight different work rehabilitation clinics answered comprehensive questionnaires at arrival to the clinic, and were followed with official register data on sickness benefits for 3 years. Structural equation models were conducted, with days on sickness benefits after work rehabilitation as the outcome.

Results

Fear avoidance beliefs for work mediated the relation between both musculoskeletal complaints and education on days on sickness benefits after work rehabilitation. The relation between musculoskeletal complaints and fear avoidance beliefs for work was furthermore fully mediated by poor physical function. Previous sick leave had a strong independent effect on continued sick leave after work rehabilitation. Fear avoidance beliefs for work did not mediate the small effect of pseudoneurological complaints on continued sick leave. Poor coping/interaction ability was neither related to continued sick leave nor fear avoidance beliefs for work.

Conclusions

The mediation model was partly supported by the data, and provides some possible new insight into how fear avoidance beliefs for work and functional ability may intervene with subjective health complaints and days on sickness benefits after work rehabilitation.

Obesity is associated with more disability at presentation and after treatment in low back pain but not in neck pain: findings from the OIOC registry

BACKGROUND

The influence on the treatment response in patients with low back pain (LBP) and neck pain (NP) is unknown. The aim of the study was to investigate the influence of body weight in patients with low back pain (LBP) and neck pain (NP) on baseline and end of treatment disability.

METHODS

Cross-sectional analysis of baseline factors. Longitudinal analysis of prospectively collected patient information at an outpatient physical therapy registry (data from June 2010 to December 2012). WHO-BMI classification was used: underweight, lean, overweight, obesity class I, obesity class II and III. The influence of body weight and a predefined set of confounders was analyzed by multiple regression models.

RESULTS

In LBP, disability increased with increasing BMI [lean = reference, obesity class I Beta 5.41 (95 % CI 0.75; 10.07), obesity class II-III Beta 7.58 (95 % CI 2.13; 13.03)]. Compared to lean patients, disability after treatment improved in overweight subjects [Beta -3.90 (95 % CI -7.4; -0.41)] but not in subjects with obesity class II-III [Beta 3.43 (95 % CI -3.81; 10.68)]. There were insufficient patients in the sample with severe obesity and therefore this trend has to be confirmed. The likelihood for meaningful important change (MID) was similar in all BMI subgroups. For patients with NP, BMI was not associated with baseline disability, and did not predict end of treatment disability or the likelihood of a MID. These findings must be interpreted with caution as BMI subgroups did not meet the required sample size.

CONCLUSION

Overweight and obesity are associated with higher levels of disability before treatment in LBP patients, but not in NP. In severely obese patients class II-III with LBP the rate of MID was lowest indicating that these patients experienced the least treatment response compared to the other groups. Further studies should address the impact of severe obesity on the prognosis of LBP. In patients with LBP, severe obesity may be an important factor to consider during the physical therapy treatment. In particular, combined treatment strategies combining weight management, cardiovascular fitness, and low back pain rehabilitation should be investigated.

Neuromuscular exercise and back counselling for female nursing personnel with recurrent non-specific low back pain: study protocol of a randomised controlled trial (NURSE-RCT)

Introduction

Nursing personnel have high risk for incidence of low back pain (LBP) followed by development of chronic pain and disability. Multiple risk factors such as patient handling, night shift work and lack of supporting work culture have been identified. In subacute LBP, high-fear avoidance is prognostic for more pain, disability and not returning to work. Lack of leisure-time physical activity predicts long-term sickness absence. The purpose of this study is to compare effectiveness of 6-month neuromuscular exercise and counselling in treating back pain in female nursing personnel with recurrent non-specific LBP pain compared with either (exercise or counselling) alone and a non-treatment control group.

Methods and analysis

The design is of a double-blinded four-arm randomised controlled trial with cost-effectiveness evaluation at 12 and 24 months. The study is conducted in 3 consecutive substudies. The main eligibility criteria are experience of LBP during the past 4 weeks with intensity of at least 2 (Numeric Rating Scale 0–10) and engagement in patient handling. Sample size was estimated for the primary outcome of pain intensity (visual analogue scale). Study measurements are outlined according to the model of International Classification of Functioning, Disability and Health, which incorporates the biopsychosocial processes assessed.

Ethics and dissemination

This study is carried out conforming to the guidelines of good scientific practice and provisions of the declaration of Helsinki. Increasing physical and mental capacity with interventions taking place immediately after working hours near the worksite may reduce development of chronic LBP and work disability in female nursing personnel with recurrent non-specific LBP.

Trial registration number

NCT04165698.

Fear-Avoidance Beliefs and Chronic Pain

Fear-avoidance (FA) beliefs are significantly associated with the experience of pain, especially when the pain becomes chronic in nature. The anticipated threat of intense pain will often result in the constant vigilance and monitoring of pain sensations, which, in turn, can cause even low-intensity sensations of pain to become unbearable for the person. Just the anticipation of increased pain or reinjury can further stimulate avoidance behaviors. A vicious cycle may develop, in which fears of increased pain or reinjury contribute to the avoidance of many activities, leading to inactivity and, ultimately, to greater disability. Anyone who assesses and treats pain-related disability should also be prepared to assess and treat pain-related FA.

[Non-randomised trial of an educational intervention based on cognitive-behavioural principles for patients with chronic low back pain attended in Primary Care Physiotherapy]

Objetivo

Valorar la influencia de una intervención educativa en la reducción del «miedo-evitación» (ME) y del «catastrofismo al dolor» (CAT) en población con lumbalgia crónica inespecífica (LCI) atendida en fisioterapia de atención primaria (AP).

Diseño

Estudio cuasiexperimental.

Emplazamiento

Centros de salud (CS) del Distrito Sanitario Costa del Sol.

Participantes

Pacientes con LCI entre 18-65 años con comprensión del idioma español; ausencia de intervenciones educativas paralelas; ausencia de banderas rojas; ausencia de deterioro cognitivo y/o fibromialgia; ausencia de cirugía dorsolumbar, y tolerancia al ejercicio físico.

Intervenciones

El grupo control recibió la EdE grupal habitual. El experimental recibió, además, un instrumento escrito para lectura domiciliaria, más la posterior puesta en común, aclaración de dudas y reestructuración de creencias y metas durante el desarrollo de las sesiones. Ambas intervenciones duraron unos 280 min (7 sesiones de 40 min).

Resultados

Las variables principales incluyeron ME y CAT. Secundariamente se valoraron dolor y discapacidad. Algunas variables «sociodemográficas» y «relacionadas con el trastorno» fueron tenidas en cuenta en el análisis.

Se observaron diferencias estadísticamente significativas en el grupo experimental versus control en la variación del ME −14 (−25,5; 0) vs −4 (−13; 0) (p = 0,009), y del CAT −9 (−18; −4) vs −4,5 (−8,25; 0) (p = 0,000). Igualmente se observaron diferencias en discapacidad (p = 0,046), pero no en dolor (p = 0,280).

Conclusiones

Los resultados deben ser considerados a la luz de las posibles limitaciones que plantea el estudio. Su naturaleza pragmática permitiría una potencial transferencia a la dinámica asistencial habitual.

Differential Neural Processing during Motor Imagery of Daily Activities in Chronic Low Back Pain Patients

Chronic low back pain (chronic LBP) is both debilitating for patients but also a major burden on the health care system. Previous studies reported various maladaptive structural and functional changes among chronic LBP patients on spine- and supraspinal levels including behavioral alterations. However, evidence for cortical reorganization in the sensorimotor system of chronic LBP patients is scarce. Motor Imagery (MI) is suitable for investigating the cortical sensorimotor network as it serves as a proxy for motor execution. Our aim was to investigate differential MI-driven cortical processing in chronic LBP compared to healthy controls (HC) by means of functional magnetic resonance imaging (fMRI). Twenty-nine subjects (15 chronic LBP patients, 14 HC) were included in the current study. MI stimuli consisted of randomly presented video clips showing every-day activities involving different whole-body movements as well as walking on even ground and walking downstairs and upstairs. Guided by the video clips, subjects had to perform MI of these activities, subsequently rating the vividness of their MI performance. Brain activity analysis revealed that chronic LBP patients exhibited significantly reduced activity compared to HC subjects in MI-related brain regions, namely the left supplementary motor area and right superior temporal sulcus. Furthermore, psycho-physiological-interaction analysis yielded significantly enhanced functional connectivity (FC) between various MI-associated brain regions in chronic LBP patients indicating diffuse and non-specific changes in FC. Current results demonstrate initial findings about differences in MI-driven cortical processing in chronic LBP pointing towards reorganization processes in the sensorimotor network.

Cross friction algometry (CFA): Comparison of pressure pain thresholds between patients with chronic non-specific low back pain and healthy subjects

Palpation is widely used to assess muscular sensitivity in clinical settings but still remains a subjective evaluation. This cross-sectional study assessed a newly developed cross-friction algometry making palpation measurable. The objective was to investigate the reliability of pressure pain thresholds obtained using Cross-Friction Algometry (CFA-PPTs) measured at the level of Erector spinae and Gluteus maximus central muscle parts, and to compare the CFA-PPTs between patients with chronic nonspecific low back pain (nCLBP) and matching healthy subjects.

PARTICIPANTS

Patients presenting nCLBP to GP's and send into a Pain Center and healthy subjects recruited via university ad valvas & flyers distribution.

OUTCOME MEASURES

30 patients with nCLBP were measured for cross-friction algometry. Other evaluations consisted of the Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI).

RESULTS

The inter- and intra-reliability were tested and found to be sufficient. The mean CFA-PPT values of the Erector spinae at levels T8, T10, L1 & L3 and the Gluteus maximus of the nCLBP group were significantly lower (p ≤ 0.001) when compared to the CFA-PPT values of the healthy group. The greatest difference (-58%) was found at L1 Erector spinae level and at the superior part of the Gluteus maximus measuring point (-59%). Within the group of patients with nCLBP it was surprising to notice that there was no significant correlation between all the reference points measured using CFA-PPTs and the outcomes of the VAS and ODI scores.

CONCLUSIONS

With the aid of CFA, the importance of local muscular disorder in the lumbar part of the Erector spinae and Gluteus maximus in patients with nCLBP is obviously demonstrated, but also reveals the very large inter-individual differences in muscular fibrosis sensitivity and/or pain behavior in daily life. This possibly re-opens the debate on which influences can be put forward as the most important: the central or the peripheral sensitization system.

Beliefs underlying pain-related fear and how they evolve: a qualitative investigation in people with chronic back pain and high pain-related fear

OBJECTIVES

The fear-avoidance model describes how the belief that pain is a sign of damage leads to pain-related fear and avoidance. But other beliefs may also trigger the fear and avoidance responses described by the model. Experts have called for the next generation of fear avoidance research to explore what beliefs underlie pain-related fear and how they evolve. We have previously described damage beliefs and suffering/functional loss beliefs underlying high pain-related fear in a sample of individuals with chronic back pain. The aim of this study is to identify common and differential factors associated with the beliefs in this sample.

DESIGN

A qualitative study employing semistructured interviews.

SETTING

Musculoskeletal clinics in Western Australia.

PARTICIPANTS

36 individuals with chronic back pain and high scores on the Tampa Scale (mean 47/68).

RESULTS

The overarching theme was a pain experience that did not make sense to the participants. The experience of pain as unpredictable, uncontrollable and intense made it threatening. Attempting to make sense of the threatening pain, participants with damage beliefs drew on past personal experiences of pain, societal beliefs, and sought diagnostic certainty. Met with diagnostic uncertainty, or diagnoses of an underlying pathology that could not be fixed, they were left fearful of damage and confused about how to 'fix' it. Participants with suffering/functional loss beliefs drew on past personal experiences of pain and sought help from healthcare professionals to control their pain. Failed treatments and the repeated failure to achieve functional goals left them unable to make 'sensible' decisions of what to do about their pain.

CONCLUSIONS

The findings raise the suggestion that sense-making processes may be implicated in the fear-avoidance model. Future research is needed to explore whether fear reduction may be enhanced by considering beliefs underlying fear and providing targeted intervention to help individuals make sense of their pain.

Pain-Related Fear, Disability, and the Fear-Avoidance Model of Chronic Pain

Chronic pain is a significant public health concern that imposes substantial burdens on individuals and healthcare systems, and factors that contribute to the development and maintenance of pain-related disability are of increasing empirical and clinical interest. Consistent with the fear-avoidance model of chronic pain, greater pain-related fear has consistently been associated with more severe disability and may predict the progression of disability over time. Recent evidence indicates that treatments designed to reduce pain-related fear are efficacious for improving disability outcomes, and several clinical trials are currently underway to test tailored intervention content and methods of dissemination. Future research in this area is needed to identify factors (e.g., substance use, comorbid psychopathology) that may influence interrelations between pain-related fear, response to treatment, and disability.

The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance

Pain-related fear avoidance (FA), a common problem for patients with painful medical conditions, involves pain-related catastrophizing cognitions, hypervigilance, and avoidance behaviors, which can ultimately lead to decreased functioning, depression, and disability. Several patient-reported instruments have been developed to measure FA, but they have been criticized for limited construct validity, inadequate item specificity, lack of cutoff scores, and missing important FA components. The Fear-Avoidance Components Scale (FACS) is a new patient-reported measure designed to comprehensively evaluate FA in patients with painful medical conditions. It combines important components of FA found in prior FA scales, while trying to correct some of their deficiencies, within a framework of the most current FA model. Psychometric evaluation of the FACS found high internal consistency (α = 0.92) and high test/retest reliability (r = 0.90-0.94, P < 0.01). FACS scores differentiated between 2 separate chronic pain patient samples and a nonpatient comparison group. When clinically relevant severity levels were created, FACS severity scores were highly associated with FA-related patient-reported psychosocial and objective lifting performance variables. These results suggest that the FACS is a psychometrically strong and reliable measure that can help healthcare providers assess FA-related barriers to function and recovery.

Fear avoidance beliefs in back pain-free subjects are reflected by amygdala-cingulate responses

In most individuals suffering from chronic low back pain, psychosocial factors, specifically fear avoidance beliefs (FABs), play central roles in the absence of identifiable organic pathology. On a neurobiological level, encouraging research has shown brain system correlates of somatic and psychological factors during the transition from (sub) acute to chronic low back pain. The characterization of brain imaging signatures in pain-free individuals before any injury will be of high importance regarding the identification of relevant networks for low back pain (LBP) vulnerability. Fear-avoidance beliefs serve as strong predictors of disability and chronification in LBP and current research indicates that back pain related FABs already exist in the general and pain-free population. Therefore, we aimed at investigating possible differential neural functioning between high- and low fear-avoidant individuals in the general population using functional magnetic resonance imaging. Results revealed that pain-free individuals without a history of chronic pain episodes could be differentiated in amygdala activity and connectivity to the pregenual anterior cingulate cortex by their level of back pain related FABs. These results shed new light on brain networks underlying psychological factors that may become relevant for enhanced disability in a future LBP episode.

Cost-effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for nonspecific low back pain: design of a stepped-wedge cluster randomised controlled trial

BACKGROUND

Low back pain (LBP) is one of the most prevalent and expensive health care problems in industrialised countries. LBP leads to high health care utility and productivity losses; leaving the individual, the employer, and society with substantial costs. To improve the care for LBP patients and reduce the high societal and financial burden of LBP, in 2010 the 'Multidisciplinary care guideline for nonspecific low back pain' was developed in the Netherlands. The current paper describes the design of a study aiming to evaluate the (cost-) effectiveness of a multifaceted strategy to implement this guideline.

METHODS

In a cluster-randomised controlled trial, the (cost-) effectiveness of a multifaceted implementation strategy will be compared to passive guideline dissemination. Using a stepped-wedge approach, participating general practitioners, physiotherapists, and occupational physicians are allocated into clusters and will attend a multidisciplinary continuing medical education training session. The timing these clusters receive the training is the unit of randomisation. LBP patients visiting the participating health care providers are invited to participate in the trial and will receive access to a multimedia intervention aimed at improving beliefs, cognitions, and self-management. The primary outcome measure of this study is patient back beliefs. Secondary outcome measures on patient level include pain, functional status, quality of life, health care utility, and productivity losses. Outcome measures on professional level include knowledge and attitude towards the guideline, and guideline adherence. A process evaluation for the implementation strategy will be performed among the health care providers and the patients. Furthermore, a qualitative subgroup analysis among patients with various ethnic backgrounds will be performed.

DISCUSSION

This study will give insight into the (cost-) effectiveness of a multifaceted implementation strategy for the Dutch multidisciplinary guideline for non-specific back pain to improve outcomes on patient and professional level. The valuable information gained with this study may prove useful for policy-makers, health care providers, and researchers who are in the process of reducing the burden of back pain on individuals and society.

TRIAL REGISTRATION

Netherlands Trial Register (NTR): NTR4329. Registered December 20th, 2013.

Cost-utility of cognitive behavioral therapy for low back pain from the commercial payer perspective

STUDY DESIGN

Markov cost-utility model.

OBJECTIVE

To evaluate the cost-utility of cognitive behavioral therapy (CBT) for the treatment of persistent nonspecific low back pain (LBP) from the perspective of US commercial payers.

SUMMARY OF BACKGROUND DATA

CBT is widely deemed clinically effective for LBP treatment. The evidence is suggestive of cost-effectiveness.

METHODS

We constructed and validated a Markov intention-to-treat model to estimate the cost-utility of CBT, with 1-year and 10-year time horizons. We applied likelihood of improvement and utilities from a randomized controlled trial assessing CBT to treat LBP. The trial randomized subjects to treatment but subjects freely sought health care services. We derived the cost of equivalent rates and types of services from US commercial claims for LBP for a similar population. For the 10-year estimates, we derived recurrence rates from the literature. The base case included medical and pharmaceutical services and assumed gradual loss of skill in applying CBT techniques. Sensitivity analyses assessed the distribution of service utilization, utility values, and rate of LBP recurrence. We compared health plan designs. Results are based on 5000 iterations of each model and expressed as an incremental cost per quality-adjusted life-year.

RESULTS

The incremental cost-utility of CBT was $7197 per quality-adjusted life-year in the first year and $5855 per quality-adjusted life-year over 10 years. The results are robust across numerous sensitivity analyses. No change of parameter estimate resulted in a difference of more than 7% from the base case for either time horizon. Including chiropractic and/or acupuncture care did not substantively affect cost-effectiveness. The model with medical but no pharmaceutical costs was more cost-effective ($5238 for 1 yr and $3849 for 10 yr).

CONCLUSION

CBT is a cost-effective approach to manage chronic LBP among commercial health plans members. Cost-effectiveness is demonstrated for multiple plan designs.

LEVEL OF EVIDENCE

2.

Change in pain, disability and influence of fear-avoidance in a work-focused intervention on neck and back pain: a randomized controlled trial

BACKGROUND

Neck and back pain are among the most common causes of prolonged disability, and development of interventions with effect on pain, disability and return to work is important. Reduction of fear avoidance might be one mechanism behind improvement after interventions. The aim of the present study was to evaluate changes in pain and disability at the 12-month follow-up of patients with neck and back pain treated with a work-focused intervention compared to patients treated with standard interventions, and the influence of improvement fear avoidance beliefs during the interventions on pain, disability and return to work at 12-month follow-up.

METHODS

413 employed patients with back or neck pain referred to secondary care, and sick-listed between 4 weeks and 12 months, were randomized to a work-focused rehabilitation or control interventions. Follow-up was conducted 4 and 12 months after inclusion. The groups were compared (independent sample t-test) regarding differences in disability scores (Oswestry disability index/neck disability index) and pain (numeric rating scale) from baseline to 12-month follow-up. Changes in fear avoidance beliefs (FABQ) from baseline to 4 month follow-up were calculated, and the association between this change and return to work, pain and disability at 12 months were tested in stepwise multiple logistic regression models.

RESULTS

Pain and, disability scores decreased to in both the work-focused and control intervention to 12-month follow-up, and there were no significant differences between the groups. FABQ decreased similarly in both groups to 4 month follow-up. The logistic regression model revealed an association between a reduced FABQ work score at 4 months and return to work within one year (adjusted OR 3.60, 95% CI 1.19 to 10.88). Reduced FABQ physical activity score at 4 months was associated with decreased disability after 12 months (adjusted OR (3.65. 95% CI 1.43 to 9.28).

CONCLUSIONS

Short work-focused rehabilitation had the same effect on pain and disability as control interventions. Reduction in FABQ-W score after treatment seems to be an important predictor for return to work in both groups.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00840697.

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.