Implicit attitude towards pictures of back-stressing activities in pain-free subjects and patients with low back pain: an affective priming study

Neural dynamics of pain modulation by emotional valence

Definitions of human pain acknowledge at least two dimensions of pain, affective and sensory, described as separable and thus potentially differentially modifiable. Using electroencephalography, we investigated perceptual and neural changes of emotional pain modulation in healthy individuals. Painful electrical stimuli were applied after presentation of priming emotional pictures (negative, neutral, positive) and followed by pain intensity and unpleasantness ratings. We found that perceptual and neural event-related potential responses to painful stimulation were significantly modulated by emotional valence. Specifically, pain unpleasantness but not pain intensity ratings were increased when pain was preceded by negative compared to neutral or positive pictures. Amplitudes of N2 were higher when pain was preceded by neutral compared to negative and positive pictures, and P2 amplitudes were higher for negative compared to neutral and positive pictures. In addition, a hierarchical regression analysis revealed that P2 alone and not N2, predicted pain perception. Finally, source analysis showed the anterior cingulate cortex and the thalamus as main spatial clusters accounting for the neural changes in pain processing. These findings provide evidence for a separation of the sensory and affective dimensions of pain and open new perspectives for mechanisms of pain modulation.

Is Fear of Harm (FoH) in Sports-Related Activities a Latent Trait? The Item Response Model Applied to the Photographic Series of Sports Activities for Anterior Cruciate Ligament Rupture (PHOSA-ACLR)

Background: Fear of Harm (FoH) predicts return to sports in Anterior Cruciate Ligament Reconstruction (ACLR) and can be assessed using the Photographic Sports Activities for ACLR (PHOSA-ACLR). This study was conducted to determine whether FoH assessed using the PHOSA-ACLR is a latent trait, and to analyze differences in PHOSA-ACLR in athletes with or without an ACL rupture. Methods: Three convenience samples completed the PHOSA-ACLR: (1) ACLR patients (n = 58; mean age 25.9 years; range 17–56; SD = 8.2; 43% male); (2) first year Physical Therapy (PT) students (n = 169; mean age = 19.2; SD = 2.0; 48% male), and (3) junior football players (n = 30; mean age = 18.3; range 17–20; SD = 3.2; 94% males). ACLR patients additionally reported functioning and Fear of Movement. PHOSA-ACLR items were analyzed with Item Response Theory using the Graded Response Model (GRM). Differences between three groups of participants were analyzed using Univariate Analysis of Variance. Results: Data fitted the two-parameter GRM, and therefore the items of the PHOSA-ACLR constitute a latent trait. There was a significant difference between the three groups in PHOSA-ACLR after controlling for age and gender (F (2, 255) = 17.1, p < 0.001). PT students reported higher levels of FoH compared to either ACLR patients or healthy soccer players. Conclusions: PHOSA-ACLR items constitute a latent trait of FoH for ACLR-specific movements. Contrary to expectations, PHOSA-ACLR is higher in first year physiotherapy students compared to patients rehabilitating from ACLR, and healthy junior soccer players.

Evaluation of implicit associations between back posture and safety of bending and lifting in people without pain

Background and aims Despite lack of support from recent in vivo studies, bending and lifting (especially with a round-back posture) are perceived as dangerous to the back. In light of this view, it has been proposed that pain-free people may hold a common implicit belief that is congruent with the idea that bending and lifting with a round-back represents danger to a person's back, however this has not been evaluated. The aims of this study were: (1) to evaluate implicit associations between back posture and safety related to bending and lifting in pain-free people; (2) to explore correlations between the implicit measure and explicit measures of back beliefs, fear of movement and safety of bending; (3) to investigate self-reported qualitative appraisal of safe lifting. Methods Exploratory cross-sectional study including 67 pain-free participants (no pain, or average pain ≤3/10 for less than one week over the previous 12 months) (52% male), who completed an online survey containing demographic data and self-reported measures of: fear of movement (Tampa Scale for Kinesiophobia for General population - TSK-G), back beliefs (Back Pain Attitudes Questionnaire BackPAQ), and bending beliefs (Bending Safety Belief - BSB - a pictorial scale with images of a person bending/lifting with round and straight back postures). Implicit associations between back posture and safety related to bending and lifting were evaluated with the Implicit Association Test (IAT). A qualitative assessment of descriptions of safe lifting was performed. Results An implicit association between "danger" and "round-back" bending/lifting was evident in all participants (IATD-score=0.65 (SD=0.45; 95% CI [0.54, 0.76]). Participants' profile indicated high fear of movement, unhelpful back beliefs, and perceived danger to round-back bending and lifting (BSBThermometer: 5.2 (SD=3.8; 95% CI [4.26, 6.13] range -10 to 10; t(67)=11.09, p<0.001). There was a moderate correlation between IAT and BSBThermometer (r=0.38, 95% CI [0.16, 0.62]). There were weaker and non-statistically significant correlations between IAT and TSK-G (r=0.28, 95% CI [-0.02, 0.47]), and between IAT and BackPAQDanger (r=0.21, 95% CI [-0.03, 0.45]). Qualitative assessment of safe lifting descriptions indicated that keeping a "straight back" and "squatting" when lifting were the most common themes. Conclusions Pain-free people displayed an implicit bias towards bending and lifting with a "round-back" as dangerous. Our findings support the idea that pain-free people may have a pre-existing belief about lifting, that the back is in danger when rounded. Research to evaluate the relationship between this implicit bias and lifting behaviour is indicated. Implications The findings of this study may have implications for ergonomic guidelines and public health information related to bending and lifting back postures. Additionally, clinicians may need to be aware of this common belief, as this may be reflected in how a person responds when they experience pain.

Automatic processes and self-regulation of illness

Research on the Commonsense Self-Regulation Model has emphasised reflective/conscious perceptual processes regarding illness threat (beliefs about symptoms, consequences, timeline, and curability) in predicting and changing coping behaviours. Understanding of illness self-regulation and avenues for intervention might be enriched by consideration of automatic processes that influence the recognition and identification of illness, response to illness, and ongoing management. This article adopts an integrative approach to (1) outline the theoretical importance of implicit processes in patients' self-regulation of illness and methods to study them; (2) review research evidence for these processes, including interventions tested to modify them; and (3) outline avenues for future research. A substantial body of research on implicit processes (cognitive bias and interpretational bias) in illness maintenance in chronic illness has recently been extended to detection and interpretation of acute illness and new perspectives relating to the self-system. There is encouraging evidence that cognitive accessibility of coping and implicit attitudes may impact upon coping behaviours. Procedures that strategically automatise coping responses and create habits have considerable promise. We outline an agenda for future research in which health psychology accepts the challenge posed by the interplay of the reflective and associative systems in promoting effective self-regulation of illness.

The Underestimated Significance of Conditioning in Placebo Hypoalgesia and Nocebo Hyperalgesia

Placebo and nocebo effects are intriguing phenomena in pain perception with important implications for clinical research and practice because they can alleviate or increase pain. According to current theoretical accounts, these effects can be shaped by verbal suggestions, social observational learning, and classical conditioning and are necessarily mediated by explicit expectation. In this review, we focus on the contribution of conditioning in the induction of placebo hypoalgesia and nocebo hyperalgesia and present accumulating evidence that conditioning independent from explicit expectation can cause these effects. Especially studies using subliminal stimulus presentation and implicit conditioning (i.e., without contingency awareness) that bypass the development of explicit expectation suggest that conditioning without explicit expectation can lead to placebo and nocebo effects in pain perception. Because only few studies have investigated clinical samples, the picture seems less clear when it comes to patient populations with chronic pain. However, conditioning appears to be a promising means to optimize treatment. In order to get a better insight into the mechanisms of placebo and nocebo effects in pain and the possible benefits of conditioning compared to explicit expectation, future studies should carefully distinguish both methods of induction.

Investigation of four self-report instruments (FABT, TSK-HC, Back-PAQ, HC-PAIRS) to measure healthcare practitioners' attitudes and beliefs toward low back pain: Reliability, convergent validity and survey of New Zealand osteopaths and manipulative physiotherapists

BACKGROUND

Healthcare practitioner beliefs influence advice and management provided to patients with back pain. Several instruments measuring practitioner beliefs have been developed but psychometric properties for some have not been investigated.

AIMS

To investigate internal consistency, test-retest reliability and convergent validity of the Fear Avoidance Beliefs Tool (FABT), the Tampa Scale of Kinesiophobia for Health Care Providers (TSK-HC), the Back Pain Attitudes Questionnaire (Back-PAQ), and the Health Care Pain and Impairment Relationship Scale (HC-PAIRS). A secondary aim was to explore beliefs of New Zealand osteopaths and physiotherapists regarding low back pain.

METHOD

FABT, TSK-HC, Back-PAQ, and HC-PAIRS were administered twice, 14 days apart.

RESULTS

Data from 91 osteopaths and 35 physiotherapists were analysed. The FABT, TSK-HC and Back-PAQ each demonstrated excellent internal consistency, (Cronbach's α = 0.92, 0.91, and 0.91 respectively), and excellent test-retest reliability (lower limit of 95% CI for intraclass correlation coefficient >0.75). Correlations between instruments (Pearson's r = 0.51 to 0.77, p < 0.001) demonstrated good convergent validity. There was a medium to large effect (Cohen's d > 0.47) for mean differences in scores, for all instruments, between professions.

CONCLUSIONS

This study found excellent internal consistency, test-retest reliability and good convergent validity for the FABT, TSK-HC, and Back-PAQ. Previously reported internal consistency, test-retest and convergent validity of the HC-PAIRS were confirmed, and test-retest reliability was excellent. There were significant scoring differences on each instrument between professions, and while both groups demonstrated fear avoidant beliefs, physiotherapist respondent scores indicated that as a group, they held fewer fear-avoidant beliefs than osteopath respondents.

Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending

BACKGROUND AND AIMS

Pain and protective behaviour are dependent on implicit evaluations of danger to the body. However, current assessment of perceived danger relies on self-report, on information of which the person is aware and willing to disclose. To overcome this limitation, attempts have been made to investigate implicit evaluation of movement-related threatening images in people with persistent low back pain (PLBP) and pain-related fear. Lack of specificity of the sample and stimuli limited those explorations. This study investigated implicit evaluations and physiological responses to images of tasks commonly reported as threatening by people with PLBP: bending and lifting. We hypothesized that people who differ in self-reported fear of bending with a flexed lumbar spine (fear of bending) would also differ in implicit evaluations and physiological responses.

METHODS

This study used a convenience sample of 44 people (54% female) with PLBP, who differed in self-reported fear of bending. Participants completed a picture-viewing paradigm with pleasant, neutral and unpleasant images, and images of people bending and lifting with a flexed lumbar spine ('round-back') to assess physiological responses (eye-blink startle modulation, skin conductance). They also completed an implicit association test (IAT) and an affective priming task (APT). Both assessed implicit associations between (i) images of people bending/lifting with a flexed lumbar spine posture ('round-back' posture) or bending/lifting with a straight lumbar spine posture ('straight-back' posture), and (ii) perceived threat (safe vs. dangerous).

RESULTS

An implicit association between 'danger' and 'round-back' bending/lifting was evident in all participants (IAT (0.5, CI [0.3; 0.6]; p<0.001) and APT (24.2, CI [4.2; 44.3]; p=0.019)), and unrelated to self-reported fear of bending (IAT (r=-0.24, 95% CI [-0.5, 0.04], p=0.117) and APT (r=-0.00, 95% CI [-0.3, 0.3], p=0.985)). Levels of self-reported fear of bending were not associated with eye-blink startle (F(3, 114)=0.7, p=0.548) or skin conductance responses (F(3, 126)=0.4, p=0.780) to pictures of bending/lifting.

CONCLUSIONS

Contrary to our expectation, self-reported fear of bending was not related to physiological startle response or implicit measures. People with PLBP as a group (irrespective of fear levels) showed an implicit association between images of a round-back bending/lifting posture and danger, but did not display elevated physiological responses to these images. These results provide insight to the understanding of the relationship between pain and fear of movement.

IMPLICATIONS

The potential clinical implications of our findings are twofold. First, these results indicate that self-report measures do not always reflect implicit associations between particular movements and threat. Implicit association tasks may help overcome this limitation. Second, a lack of the predicted physiological and behavioural responses may reflect that the visualization of a threatening task by people in pain does not elicit the same physiological defensive responses measured in people with fear of specific objects. It may be necessary to expose the person to the actual movement to elicit threat-responses. Together, these results are consistent with current views of the role of 'fear' in the fear-avoidance model, in which a fear response may only be elicited when the threat is unavoidable.

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.

Pain-related and negative semantic priming enhances perceived pain intensity

BACKGROUND

Negative affective and pain-related cues, such as pictures or words, have been shown to act as primes and enhance the perceived intensity of subsequent painful events. For pain-related semantic primes, it remains unclear whether this effect depends on negative valence itself or, specifically, on the pain-relatedness of the words.

OBJECTIVES

To investigate the effect of pain-related, negative affective (pain-unrelated) and neutral semantic primes on the perception of subsequent noxious target stimuli.

METHODS

Pain ratings in response to noxious electrical stimulation of light and moderate intensity were examined in 39 healthy subjects after subjects were exposed to semantic primes of different meaning and valence (pain-related, negative, positive and neutral adjectives) presented with different interstimulus intervals (0 ms, 500 ms and 1500 ms).

RESULTS

Increased pain ratings of noxious stimuli were observed following pain-related and negative compared with neutral primes.

DISCUSSION

The results support the motivational priming theory for semantic stimuli, indicating that affectively negative semantic primes increase subjective pain intensity. However, a specific pain-related priming effect was not reliably demonstrated. Additionally, it is shown that experimental parameters (ie, stimulus intensity and interstimulus interval) modify the extent of negative and pain-related semantic priming.

CONCLUSIONS

Verbal priming plays a role for the perception of noxious stimuli in a time-dependent manner.

Does a patient's physical activity predict recovery from an episode of acute low back pain? A prospective cohort study

Background

Advice to remain active and normalisation of activity are commonly prescribed in the management of low back pain (LBP). However, no research has assessed whether objective measurements of physical activity predict outcome and recovery in acute low back pain.

Method

The aims of this study were to assess the predictive relationship between activity and disability at 3 months in a sub-acute LBP population. This prospective cohort study recruited 101 consenting patients with sub-acute LBP (< 6 weeks) who completed the Roland Morris Disability Questionnaire (RMDQ), the Visual Analogue Scale, and resumption of full ‘normal’ activity question (Y/N), at baseline and 3 months. Physical activity was measured for 7 days at both baseline and at 3 months with an RT3 accelerometer and a recall questionnaire.

Results

Observed and self-reported measures of physical activity at baseline and change in activity from baseline to 3 months were not independent predictors of RMDQ (p > 0.05) or RMDQ change (p > 0.05) over 3 months. A self-report of a return to full ‘normal’ activities was significantly associated with greater RMDQ change score at 3 months (p < 0.001). Paired t-tests found no significant change in activity levels measured with the RT3 (p = 0.57) or the recall questionnaire (p = 0.38) from baseline to 3 months.

Conclusions

These results question the predictive role of physical activity in LBP recovery, and the assumption that activity levels change as LBP symptoms resolve. The importance of a patient’s perception of activity limitation in recovery from acute LBP was also highlighted.

Trial registration

Clinical Trial Registration Number, ACTRN12609000282280

Sequential priming measures of implicit social cognition: a meta-analysis of associations with behavior and explicit attitudes

In a comprehensive meta-analysis of 167 studies, the authors found that sequential priming tasks were significantly associated with behavioral measures (r = .28) and with explicit attitude measures (r = .20). Priming tasks continued to predict behavior after controlling for the effects of explicit attitudes. These results generalized across a variety of study domains and methodological variations. Within-study moderator analyses revealed that priming tasks have good specificity, only predicting behavior and explicit measures under theoretically expected conditions. Together, these results indicate that sequential priming-one of the earliest methods of investigating implicit social cognition--continues to be a valid tool for the psychological scientist.

Neural correlates of fear of movement in high and low fear-avoidant chronic low back pain patients: an event-related fMRI study

The fear-avoidance model postulates that in chronic low back pain (CLBP) a fear of movement is acquired in the acute phase, which leads to subsequent avoidance of physical activity and contributes to the pain syndrome's becoming chronic. In the present event-related functional magnetic resonance imaging (fMRI) study of the neural correlates of the fear of movement, 60 women (30 CLBP patients, 15 healthy controls, and 15 women with spider phobia; mean age 46.8±9.8 years) participated. The CLBP patients were divided into a high and low fear-avoidant group on the basis of the Tampa Scale of Kinesiophobia. The participants viewed photographs depicting neutral and aversive (back-stressing) movements, generally fear-inducing and neutral pictures from the International Affective Picture System, and pictures of spiders while fMRI data were acquired. It was hypothesized that the high fear-avoidant CLBP patients would show fear-related activations when viewing the aversive movements and that they would differ from CLBP patients with low fear-avoidance and controls in this regard. No such activations were found for high or low fear-avoidant CLBP patients. The random-effects analysis showed no differences between high and low fear-avoidant CLBP patients or high fear-avoidant CLBP patients and controls. Normal fear-related activations were present in the high fear-avoidant CLBP patients for the generally fear-inducing pictures, demonstrating the validity of the stimulation paradigm and a generally unimpaired fear processing of the high fear-avoidant CLBP patients. Our findings do not support the fear component of the fear avoidance model.

Understanding the Role of Injury/Illness Sensitivity and Anxiety Sensitivity in (Automatic) Pain Processing: An Examination Using the Extrinsic Affective Simon Task

Three fundamental fears are assumed to underlie psychopathology: Anxiety Sensitivity (AS), Injury/illness sensitivity (IS), and Fear of Negative Evaluation (FNE). Both AS and IS may form risk factors for the development and exacerbation of chronic pain. The current research examines the relation between these fears and automatic threat appraisal for pain-related stimuli. Study 1 (n=48) additionally examined content-specific associations of AS and FNE with the automatic threat appraisal of, respectively, panic and social evaluative cues. Study 2 (n=60) additionally focused on the association of IS and AS with the engagement in health protecting behavior, and the use of health care services. Both studies found evidence for an automatic threat appraisal of aversive stimuli. Study 2 demonstrated a positive association between the automatic threat appraisal for pain-related stimuli and individuals' IS levels. IS was found to be the single best predictor of the tendency to engage in health protecting behavior, whereas AS was the single best predictor of the reported use of health care services.

PERSPECTIVE

This study contributes to the field of knowledge on putative risk factors for chronic pain. Results demonstrate an automatic threat appraisal toward pain-related stimuli that is related to vulnerability traits for pain. This automatic threat appraisal might initiate relatively spontaneous (nonstrategic) pain-maintaining behavioral responses.

Attitudes to back pain amongst musculoskeletal practitioners: A comparison of professional groups and practice settings using the ABS-mp

Chiropractors, osteopaths and physiotherapists play key roles in the management of low back pain (LBP) patients in the UK. We investigated the attitudes of these three professional groups to back pain using a recently developed and validated questionnaire, the Attitudes to Back Pain Scale for musculoskeletal practitioners (ABS-mp). A cross-sectional questionnaire survey was sent to 300 of each professional group (n=900). Responses were analysed from 465 practitioners: 132 chiropractors (28%), 159 osteopaths (34%) and 174 physiotherapists (37%). Overall, all three groups endorse a psychosocial approach to treatment, and see re-activation as a primary goal. However, physiotherapists and osteopaths tend to endorse attitudes towards limiting the number of treatment sessions offered to LBP patients more than chiropractors, and chiropractors endorse a more biomedical approach than physiotherapists. When practice setting (NHS versus private practice) was considered (in physiotherapists alone), physiotherapists working for the NHS endorsed limiting the number of treatment sessions more than those working in the private sector and would also less frequently advise their patients to restrict activities and be vigilant. The results may help explain current clinical practice patterns observed in these groups and their uptake of clinical guideline recommendations.

Measuring Fear of Movement/(Re)injury in Chronic Low Back Pain Using Implicit Measures

Fear of movement/(re)injury is assumed to contribute to the development and maintenance of chronic low back pain (CLBP) in a subgroup of patients. Studying fear of movement/(re)injury with implicit attitude measures, without the awareness of the patient, might be a valuable addition to self-report questionnaires. The aims of the current study were to investigate whether CLBP patients demonstrate more implicit fear of movement/(re)injury than healthy controls, and whether 2 implicit measures are related to each other, and to an explicit self-report measure of fear of movement/(re)injury. A group of 66 CLBP patients and 30 healthy controls took part in this study. In addition to self-report questionnaires, fear of movement/(re)injury was implicitly assessed by the Extrinsic Affective Simon Task (EAST) and the Go-No-Go-Association Task (GNAT) that aimed to determine the association between back-stressing movements and the evaluation "threatening". On both implicit tasks it was found that neither CLBP patients nor healthy controls demonstrated implicit fear of movement/(re)injury, and that CLBP patients did not differ from healthy controls in their level of implicit fear of movement/(re)injury. In general, no associations were found between the EAST and the GNAT, or between implicitly measured and self-reported fear of movement/(re)injury. One major caveat in drawing inferences from these findings is the poor reliability of these implicit measures. Research towards the psychometric properties of these measures should first be expanded before modifying, and applying, them to more complex domains such as fear of movement/(re)injury.

The Attitudes to Back Pain Scale in Musculoskeletal Practitioners (ABS-mp)

OBJECTIVES

Little is known about practitioners' beliefs and attitudes to the treatment of low back pain, and whether these influence their clinical decisions, intervention strategies, and patient-centered outcomes. This study aimed to develop, test, and explore the underlying dimensions of a new questionnaire, the Attitudes to Back Pain Scale (ABS), in a specific group of clinicians, practitioners who specialize in musculoskeletal therapy.

METHODS

Items for the draft questionnaire were derived from interviews with practitioners (chiropractors, osteopaths, and physiotherapists). The draft questionnaire (52 items) sought to assess practitioners' attitudes concerning role and self-image plus their beliefs about treatment goals and prognosis of low back pain. The questionnaire was sent to a random selection of 300 practitioners from each professional group, and 546 (61%) responded. Split-sample analyses were performed using exploratory and confirmatory factor analysis.

RESULTS

Separate exploratory analyses were done for attitudes concerned with personal interaction (34 items) and attitudes about treatment orientation (18 items), producing six domains: limitations on sessions, psychologic, connection to health care system, confidence and concern, reactivation, and biomedical. Confirmatory analyses indicated that the model tested presented a good fit. Validity interviews revealed high agreement of categorization and low levels of difficulty in categorizing the items.

CONCLUSIONS

The internal structure of the new questionnaire not only shows excellent psychometric properties and good face validity, but also has the added advantage of being developed with a specific clinical context in mind. Additional evaluation is required to fully describe the psychometric integrity of this instrument.

Low back pain, disability and back pain myths in a community sample: prevalence and interrelationships

This study investigated the prevalence of back pain, disability, and, of most importance, the presence of misconceptions about low back pain (LBP), its diagnosis and treatment in a bicultural community sample (Belgium). Using the Graded Chronic Pain Scale [Pain 50 (1992) 133] persons were classified according to pain intensity and disability in five subgroups. The interrelationship between LBP beliefs and these five subgroups was also investigated. In our sample (n=1624) the 6-month prevalence of low back pain was 41.8%. Only in 8.2% back pain was disabling. Misconceptions about back pain were widespread, even in the group reporting no back pain. The least misconceptions were found to exist in participants with mild LBP without disability. It is suggested that recovery from an episode of acute low back pain is an active process that involves a correction of beliefs about harm, about the need to restrict physical activities and about medical diagnosis and cure. Finally, it is argued that community actions may be useful to correct LBP myths in order to prevent the development of long-term disability due to LBP.

The Fear of Pain questionnaire: factor structure in samples of young, middle-aged and elderly European people

The present study examined the factor structure of the Fear of Pain questionnaire in three independent samples composed of European young adults, middle-aged, and elderly people. Seven hundred and thirty one adults (426 females and 305 males) were presented with the French adaptation of the questionnaire (30 items) and with an Exposure to Painful Situations questionnaire that contained the same items as the Fear of Pain questionnaire and where participants were instructed to indicate all the painful situations they have experienced in the past. When tested on the whole set of 30 items, the correlated three-factor model evidenced in previous studies - Severe pain, Minor pain and Medical pain - poorly fit the data. When tested on a set of 15 two-item parcels, the fit of this model was much better but the correlations between factors were very high. When tested on a reduced set of 15 items, the model fit the data as well as when it was tested on the set of 15 parcels, and the correlations between the three factors were lower. The study also examined the link between previous exposure to pain and fear of pain. The hypothesis that previous "natural" exposure to pain should generally result in a decrease in fear of pain was supported by the data. For 14 items, the exposure effect was moderate to strong.