Do Fear-Avoidance Beliefs Play a Role on the Association Between Low Back Pain and Sickness Absence? A Prospective Cohort Study Among Female Health Care Workers

Understanding Work Ability in Employees with Pain and Stress-Related Ill-Health: An Explorative Network Analysis of Individual Characteristics and Psychosocial Work Environment

PURPOSE

There is a wide range of individual and work environment factors that influence work ability among workers with pain and stress-related ill-health. The multiple interactions and overlap between these factors are insufficiently understood, and a network approach could mitigate limitations of previous research. This pilot study aimed to explore interactions between individual characteristics and psychosocial work environment and potential links to long-term work ability.

METHODS

Prospective data from a prevention project was used. Individuals (N = 147) with pain and/or stress-related ill-health (95% women) at public sector workplaces filled out baseline questionnaires about a collection of individual and work environment factors, which were used for constructing undirected networks. The model was run in three subsamples of workplaces. Finally, a separate model was established with work ability at 6-month follow-up as outcome variable. A shortest pathway analysis was calculated to identify mediators of work ability.

RESULTS

Symptom catastrophizing and perceived stress were the most influential factors in all network models. Symptom catastrophizing and pain-disability risk were found to mediate the relation between perceived stress and long-term work ability. Further, demand-control-support factors were interrelated, and patterns of interaction differed between different types of workplaces.

CONCLUSION

The findings support the importance of individual factors, specifically symptom catastrophizing in an individual's coping with pain or stress-problems and its influence on long-term work ability. Catastrophizing might play a role in stress-related disorders which should be further investigated. Individual and work environment factors interact and vary across context, which needs to be taken into consideration to prevent pain and stress-related ill-health at work.

Influence of Family-Learned Fear-of-Pain on Patients

BACKGROUND

Fear-of-pain is a common feeling of patients and their family who experience or witness severe or chronic pain. Fear-of-pain may disturb patient's recovery, and also influence family support to assist patients' recovery.

AIM

This study is to measure the level of family support for each patient; evaluate the extent of the supporting families' fear-of-pain; and identify possible interventions in family support and family fear-of-pain.

METHODS

This cross-sectional descriptive research involved 77 participants in the orthopedics department of a tertiary hospital by convenience sampling. The online questionnaire includes general information, and scales of fear-of-pain, pain anxiety, pain vigilance and awareness, pain catastrophizing, and family support. T-test, Pearson correlation analysis and Spearman correlation analysis were used to analyze data.

RESULTS

Most participants reported that they experienced a moderate-to-high level of fear-of-pain, pain anxiety, pain vigilance and awareness. A total of 15.6% of participants are at risk of pain catastrophizing. The family's pain vigilance and awareness, and fear-of-pain were often similar to those of the patient, and their levels of pain anxiety and catastrophizing were often higher than the patient's. Family support and families' fear-of-pain affect patients' feelings of pain and families' behavior in decision-making for patient recovery, necessitating the development of interventions for patients' families.

CONCLUSIONS

Family members can develop the fear-of-pain from witnessing painful experiences and may exhibit fear-avoidance behaviors in deciding on patients' rehabilitation plan. Family support, including the type of relationship with families, and length of time family spent with the patient, had an effect on patients' pain and fear-of-pain.

Neuromuscular exercise and counseling for treating recurrent low back pain in female healthcare workers-Findings from a 24-month follow-up study of a randomized controlled trial

BACKGROUND

Female healthcare workers have a high prevalence of low back pain (LBP)-related sickness absence. Here, we report findings of a 24-month follow-up of a previously published 6-month randomized controlled trial (RCT).

METHODS

By adopting an RCT with 6 months of intervention and follow-up at 6, 12, and 24 months, we assessed the maintenance of changes in the effectiveness (LBP and fear of pain) of the interventions (neuromuscular exercise [NME], back-care counseling, both combined) using a generalized linear mixed model adjusted for baseline covariates. The incremental cost-effectiveness ratio was calculated in terms of quality-adjusted life years (QALY). A bootstrap technique was used to estimate the uncertainty around a cost-effectiveness acceptability curve.

RESULTS

Of the 219 females, 71% had data at 24 months. Between 6 and 24 months, LBP intensity (primary outcome) remained low in all intervention arms (-20% to -48%) compared to the control (-10% to -16%). Pain interfering with work remained low in the combined and exercise arms for up to 24 months. At 24 months, the total costs were lowest in the combined arm (€484 vs. €613-948, p < 0.001), as were the number of back-related sickness absence days (0.16 vs. 1.14-3.26, p = 0.003). The analysis indicated a 95% probability of the combined arm to be cost-effective per QALY gained at €1120.

CONCLUSIONS

Six months of weekly NME combined with four counseling sessions was cost-effective for treating LBP and the effect was maintained over 24 months.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01465698, 7/11/2011, prospective.

Correlation between standing posture during work and low back and lower limb pain among cleaners and caregivers of older adults

ABSTRACT Maintaining a standing posture during work has been associated with musculoskeletal symptoms. Few studies, however, assess the standing time using objective measures. Thus, this study aimed to verify whether standing time at work is associated with lower back and lower limb pain in the last seven days and last 12 months in caregivers of older adults and cleaners. This is a cross-sectional study. Standing time at work was quantified using inclinometers attached to the workers’ thigh and spine. Musculoskeletal symptoms were assessed using the Nordic Musculoskeletal Questionnaire. Data were analyzed using the point-biserial correlation coefficient (rpb) between standing time at work and the presence of musculoskeletal symptoms. The analyses were performed using the SPSS software, adopting 5% significance level. Workers spend most of their time standing still (41.3%) or walking (39.3%). The presence of symptoms in the lower back was positively correlated with standing time (rpb=0.52; p<0.05). Walking time was negatively correlated with symptoms at the hip in the last 12 months (rpb=−0.53; p<0.05) and running time with symptoms at the hip, in the last seven days, (rpb=−0.43; p<0.05) and the lower back (rpb=−0.43; p<0.05). Longer standing time was correlated with the presence of symptoms in the lower back. Meanwhile, less time walking and running were correlated with the presence of musculoskeletal symptoms in the hips and lower back.

Correlação entre a postura em pé durante o trabalho e dor na coluna lombar e nos membros inferiores em trabalhadoras da limpeza e cuidadoras de idosos

RESUMO A postura em pé durante o trabalho tem sido associada a sintomas musculoesqueléticos. Entretanto, há poucos estudos que avaliam o tempo em pé utilizando medidas objetivas. Assim, o objetivo deste estudo foi verificar se o tempo em pé no trabalho está associado com dor na coluna lombar e nos membros inferiores nos últimos sete dias e 12 meses em cuidadoras de idosos e trabalhadoras da limpeza. Trata-se de estudo transversal, em que o tempo em pé no trabalho foi quantificado por meio de inclinômetros fixados na coxa e na coluna vertebral, e os sintomas musculoesqueléticos foram avaliados por meio do Questionário Nórdico de Sintomas Osteomusculares. Os dados foram analisados por meio da correlação ponto bisserial (rpb) entre o tempo em pé no trabalho e a presença de sintomas musculoesqueléticos. As análises foram realizadas por meio do software SPSS e o nível de significância adotado foi de 5%. Verificou-se que as trabalhadoras passam a maior parte do tempo em pé paradas (41,3%) ou andando (39,3%). Houve correlação positiva entre a presença de sintoma na lombar e o tempo em pé (rpb=0,52; p<0,05) e correlação negativa entre o tempo andando e sintomas no quadril (rpb=−0,53; p<0,05) nos últimos 12 meses e o tempo correndo e sintomas no quadril (rpb=−0,43; p<0,05) e na coluna lombar (rpb=−0,43; p<0,05) nos últimos sete dias. O maior tempo em pé foi correlacionado com a presença de sintomas na lombar; enquanto o menor tempo andando e correndo foram correlacionados com a presença de sintomas no quadril e na coluna lombar.

The association between work-related physical and psychosocial factors and musculoskeletal disorders in healthcare workers: Moderating role of fear of movement

Objectives

Knowledge is lacking on the interaction between fear of movement (FOM) and work‐related physical and psychosocial factors in the development and persistence of musculoskeletal disorders (MSDs).

Methods

In this cross‐sectional study, 305 healthcare workers from several Belgian hospitals filled out a questionnaire including sociodemographic factors, work‐related factors (social support, autonomy at work, workload, and physical job demands), FOM, and MSDs for different body regions during the past year. Path analysis was performed to investigate (1) the association between the work‐related factors, FOM and MSDs, and (2) the moderating role of FOM on the association between the work‐related factors and MSDs among healthcare workers.

Results

Complaints were most frequently located at the neck–shoulder region (79.5%) and lower back (72.4%). Physical job demands (odds ratio [OR] 2.38 and 95% confidence interval [CI] 1.52–3.74), autonomy at work (OR 1.64 CI [1.07–2.49]) and FOM (OR 1.07 CI [1.01–1.14] and OR 1.12 CI [1.06–1.19]) were positively associated with MSDs. Healthcare workers who experienced high social support at work (OR 0.61 CI [0.39–0.94]) were less likely to have MSDs. Fear of movement interacted negatively with workload (OR 0.92 CI [0.87–0.97]) and autonomy at work (OR 0.94 CI [0.88–1.00]) on MSDs.

Conclusions

Work‐related physical and psychosocial factors as well as FOM are related to MSDs in healthcare workers. FOM is an important moderator of this relationship and should be assessed in healthcare workers in addition to work‐related physical and psychosocial factors to prevent or address MSDs.

Demographic, Lifestyle, and Physical Health Predictors of Sickness Absenteeism in Nursing: A Meta-Analysis

Background

Sickness absenteeism is an area of concern in nursing and is more concerning given the recent impacts of the COVID-19 pandemic on healthcare. This study is one of two meta-analyses that examined sickness absenteeism in nursing. In this study, we examined demographic, lifestyle, and physical health predictors.

Methods

We reviewed five databases (CINAHL, ProQuest Allied, ProQuest database theses, PsycINFO, and PubMed) for our search. We registered the systematic review (CRD de-identified) and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Additionally, we used the Population/Intervention/Comparison/Outcome Tool to improve our searches. Results: Following quality testing, 17 articles were used for quantitative synthesis. Female employees were at higher risks of sickness absenteeism than their male counterparts (OR = 1.73; 95% CI: 1.33-2.25). Nursing staff who rated their health as poor had a greater likelihood of experiencing sickness absence (OR = 1.38; 95% CI: 1.19-1.60). Also, previous sick leave predicted future leaves (OR = 3.35; 95% CI: 1.37-8.19). Moreover, experiencing musculoskeletal pain (OR = 2.41 95% CI: 1.77-3.27) increased the likelihood of sickness absence with greater odds when it is a back pain (OR = 3.05; 95% CI: 1.66-5.62). Increased age, physical activity, and sleep were not associated with sick leave.

Conclusion

Several variables were statistically associated with the occurrence of sickness absenteeism. One primary concern is the limited research in this area despite alarming rates of sick leave in healthcare. More research is required to identify predictors of sickness absence, and thereby, implement preventative measures.

Early Occupational Intervention for People with Low Back Pain in Physically Demanding Jobs: 1-year Follow-up Results of the Randomized Controlled GOBACK Trial

STUDY DESIGN

Randomized controlled trial with 1-year follow up.

OBJECTIVE

The aim of this study was to assess whether people with low back pain (LBP) and self-reported physically demanding jobs, benefit from an occupational medicine intervention, in addition to a single hospital consultation and a magnetic resonance imaging, at 1 year of follow-up. Secondly, to examine whether the positive health effects, found in both groups at 6 months, persist at 1-year follow-up.

SUMMARY OF BACKGROUND DATA

The prevalence of LBP is high in the working population, resulting in a substantial social and economic burden. Although there are many guidelines available on the management of LBP, including multidisciplinary biopsychosocial rehabilitation, they provide limited guidance on the occupational medicine aspects.

METHODS

As reported previously, 305 participants with LBP and self-reported physically demanding jobs were enrolled in the randomized controlled study and randomly allocated to clinical care with additional occupational medicine intervention or clinical care alone. Data were collected at baseline, 6 months, and 1 year. Outcomes included in the present 1-year follow-up study are changes in neuropathic pain (painDETECT questionnaire), severity of pain (0-10 numerical rating scale), disability (Roland Morris Disability Questionnaire), fear-avoidance beliefs (FABQ), physical, and mental quality of life (short-form 36).

RESULTS

The study showed no effect of an occupational intervention on neuropathic pain, fear-avoidance beliefs, physical and mental quality of life nor disability measured after 1 year. The positive effects found at 6 months in both groups, remained at 1-year follow-up.

CONCLUSION

The results suggest that a thorough clinical consultation, with focus on explaining the cause of pain and instructions to stay active, can promote long-lasting physical and mental health in individuals with LBP. Therefore, additional occupational interventions could focus on altering occupational obstacles on a structural level.Level of Evidence: 2.

Education as a strategy for managing occupational-related musculoskeletal pain: a scoping review

BACKGROUND

Musculoskeletal (MSK) pain is the primary contributor to disability worldwide. There is a growing consensus that MSK pain is a recurrent multifactorial condition underpinned by health and lifestyle factors. Studies suggest that education on work-related pain and individualised advice could be essential and effective for managing persistent MSK pain.

OBJECTIVE

The objective of this scoping review was to map the existing educational resources for work-related MSK (WRMSK) pain, and the effects of implementing educational strategies in the workplace on managing WRMSK pain.

METHODS

This scoping review assessed original studies that implemented and assessed education as a strategy to manage WMSK pain. Literature search strategies were developed using thesaurus headings (ie, MeSH and CINAHL headings) and free-text search including words related to MSK in an occupational setting. The search was carried out in PubMed, CINAHL, Cochrane Library and Web of Science in the period 12-14 February 2019.

RESULTS

A total of 19 peer-reviewed articles were included and the study design, aim and outcomes were summarised. Of the 19 peer-reviewed articles, 10 randomised controlled trial (RCT) studies assessed the influence of education on work-related MSK pain. Many studies provided a limited description of the education material and assessed/used different methods of delivery. A majority of studies concluded education positively influences work-related MSK pain. Further, some studies reported additive effects of physical activity or ergonomic adjustments.

CONCLUSIONS

There is a gap in knowledge regarding the best content and delivery of education of material in the workplace. Although beneficial outcomes were reported, more RCT studies are required to determine the effects of education material as compared with other interventions, such as exercise or behavioural therapy.

Association between high fear-avoidance beliefs about physical activity and chronic disabling low back pain in nurses in Japan

Background

High prevalence of low back pain (LBP) in nurses has been reported globally. Ergonomic factors and work-related psychosocial factors have been focused on as risk factors. However, evidence on the role of fear-avoidance beliefs (FABs) concerning LBP in nurses is lacking. This study examined LBP prevalence and the association between FABs and chronic disabling LBP that interfered with work and lasted ≥ 3 months.

Methods

Female nurses (N = 3066; mean age = 35.8 ± 10.6 years) from 12 hospitals in Japan participated. A self-reported questionnaire was used to collect information on sociodemographics, LBP, work-related factors, and psychological distress. FABs about physical activity were assessed using a subscale from the FAB Questionnaire (score range = 0–24). The participants were asked to choose one of four statements regarding their LBP in the past 4 weeks: 1) I did not have LBP, 2) I had LBP without work difficulty, 3) I had LBP with work difficulty but without requiring absence from work, and 4) I had LBP requiring absence from work. If the participant had LBP in the past 4 weeks, it was also inquired if the LBP had lasted for ≥ 3 months. Chronic disabling LBP was defined as experiencing LBP with work difficulty in the past 4 weeks which had lasted for ≥ 3 months. In the nurses who had experienced any LBP in the past 4 weeks, we examined the association between FABs and experiencing chronic disabling LBP using multiple logistic regression models adjusting for pain intensity, age, body mass index, smoking status, psychological distress, hospital department, weekly work hours, night shift work, and the12 hospitals where the participants worked.

Results

Four-week and one-year LBP prevalence were 58.7 and 75.9%, respectively. High FABs (≥ 15) were associated with chronic disabling LBP (adjusted odds ratio = 1.76, 95% confidence interval [1.21–2.57], p = 0.003).

Conclusions

LBP is common among nurses in Japan. FABs about physical activity might be a potential target for LBP management in nurses.

Trial registration

UMIN-CTR UMIN000018087. Registered: June 25, 2015.

Physical demand at work and sick leave due to low back pain: a cross-sectional study

OBJECTIVES

To investigate if self-reported high physical demand at work, objective physical workload using a job exposure matrix (JEM) and fear-avoidance beliefs are associated with reported sick leave in the previous year in persons with low back pain (LBP). Second, to investigate if the effects of fear-avoidance and self-reported high physical demand at work on sick leave are modified by the objective physical workloads.

SETTINGS

Participants were recruited from general practice and by advertisement in a local newspaper.

PARTICIPANTS

305participants with a current period of 2-4 weeks LBP and self-reported difficulty in maintaining physically demanding jobs due to LBP were interviewed, clinically examined and had an MRI at baseline.

MAIN OUTCOME MEASURES

Independent variables were high fear-avoidance, self-reported high physical demand at work and objective measures of physical workloads (JEM). Outcome was self-reported sick leave due to LBP in the previous year. Logistic regression and tests for interaction were used to identify risk factors and modifiers for the association with self-reported sick leave.

RESULTS

Self-reported physically demanding work and high fear-avoidance were significantly associated with prior sick leave due to LBP in the previous year with OR 1.75 95% CI (1.10 to 2.75) and 2.75 95% CI (1.61to 4.84), respectively. No objective physical workloads had significant associations. There was no modifying effect of objective physical workloads on the association between self-reported physical demand at work/high fear-avoidance and sick leave.

CONCLUSIONS

Occupational interventions to reduce sick leave due to LBP may have to focus more on those with high self-reported physical demands and high fear-avoidance, and less on individuals with the objectively highest physical workload.

TRIAL REGISTRATION NUMBER

NCT02015572; Post-results.

How was a national moving and handling people guideline intended to work? The underlying programme theory

In healthcare, moving and handling people (MHP) often cause musculoskeletal disorders. To prevent musculoskeletal disorders due to MHP, many national evidence-based guidelines have been developed. However, little is known about how these guidelines were intended to work, i.e. their 'programme theory', how implementation by intended users is influenced by contextual factors and mechanisms to produce outcomes. This paper identifies the programme theory of a national MHP guideline (MHPG) using thematic analysis of the MHPG document, three organisational planning documents, and interviews with MHPG developers. The analysis identified the intended users of the MHPG as health and safety managers and MHP coordinators. The programme theory comprised contextual factors, potentially hindering (e.g. budget constraints) or facilitating (e.g. changing demographics) implementation, being influenced by mechanisms mainly based on ethical (quality of care, evidence-based practices), and economic reasoning (reducing cost of MHP, return on investment) to reduce injuries caused by MHP - the intended outcome.

Effectiveness and cost-effectiveness of neuromuscular exercise and back care counseling in female healthcare workers with recurrent non-specific low back pain: a blinded four-arm randomized controlled trial

Background

Registered healthcare workers worldwide have a high prevalence of work-related musculoskeletal disorders, particularly of the back. Multidisciplinary interventions among these workers have improved fear avoidance beliefs, but not low back pain (LBP) and related sickness absences, cost-effectiveness studies are scarce. Our purpose was to investigate the effectiveness and cost-effectiveness of three intervention-arms (combined neuromuscular exercise and back care counselling or either alone) compared with non-treatment.

Methods

We randomly assigned female healthcare workers with recurrent non-specific LBP to one of four study-arms: Combined neuromuscular exercise and back care counseling; Exercise; Counseling; and no intervention Control. We assessed the effectiveness of the interventions on intensity of LBP, pain interfering with work and fear avoidance beliefs against the Control, and calculated the incremental cost-effectiveness ratios for sickness absence and QALY.

Results

We conducted three sub-studies in consecutive years of 2011, 2012, and 2013 to reach an adequate sample size. All together 219 women were randomized within each sub-study, of whom 74 and 68% had adequate questionnaire data at 6 and 12 months, respectively. No adverse events occurred. Compliance rates varied between intervention-arms. After 12 months, the Combined-arm showed reduced intensity of LBP (p = 0.006; effect size 0.70, confidence interval 0.23 to 1.17) and pain interfering with work (p = 0.011) compared with the Control-arm. Work-related fear of pain was reduced in both the Combined- (p = 0.003) and Exercise-arm (p = 0.002). Physical activity-related fear was reduced only in the Exercise-arm (p = 0.008). During the study period (0–12 months) mean total costs were lowest in the Combined-arm (€476 vs. €1062–€1992, p < 0.001) as were the mean number of sickness absence days (0.15 vs. 2.29–4.17, p = 0.025). None of the intervention-arms was cost-effective for sickness absence. There was 85% probability of exercise-arm being cost-effective if willing to pay €3550 for QALY gained.

Conclusions

Exercise once a week for 6 months combined with five sessions of back care counseling after working hours in real-life settings effectively reduced the intensity of LBP, work interference due to LBP, and fear of pain, but was not cost-effective.

Trial registration

ClinicalTrials.gov, NCT01465698 November 7, 2011 (prospective).

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6293-9) contains supplementary material, which is available to authorized users.

Association between pain-related fear and presenteeism among eldercare workers with low back pain

BACKGROUND

Presenteeism (work productivity loss at work) and low back pain (LBP) are prevalent among eldercare workers. Presenteeism is a serious emerging problem in an occupational setting. While many studies report the impact of pain-related fear on absenteeism, its impact on presenteeism remains unclear.

METHODS

We conducted a cross-sectional study to investigate the association between pain-related fear and presenteeism among 505 eldercare workers with LBP. We measured pain-related fear using the 11-item Tampa Scale for Kinesiophobia (TSK-11). We used the Work Limitations Questionnaire (WLQ) to estimate productivity loss due to presenteeism with items including Time Management, Mental-Interpersonal Demands, Physical Demands and Output Demands. The presenteeism was categorized into no (<5%), mild (5%-10.9%), moderate (11%-16.9%) and severe presenteeism (≥17%). We further performed ordinal logistic regression analyses, and the covariates were age, sex, pain intensity, pain disability and psychosocial factors. Multiple imputation was conducted to provide informed estimates for observations with missing data.

RESULTS

After adjustment, a higher TSK score was significantly associated with a higher presenteeism (proportional OR = 1.10, 95% CI = 1.06-1.15). A significant association of TSK with all WLQ subscales was retained even after the adjustment (Time Management: proportional OR = 1.04, 95% CI = 1.01-1.08; Mental-Interpersonal Demands: proportional OR = 1.08, 95% CI = 1.04-1.12; Physical Demands: proportional OR = 1.04, 95% CI = 1.01-1.08; and Output Demands: proportional OR = 1.06, 95% CI = 1.02-1.10).

CONCLUSIONS

Our findings suggest that pain-related fear is an important factor related to presenteeism among eldercare workers with LBP.

SIGNIFICANCE

This study describes an independent association of pain-related fear with presenteeism among eldercare workers with low back pain. Pain-related fear could be considered a vital factor of presenteeism in addition to absenteeism.

Resilience and Vulnerability Factors When Pain is Acute as Predictors of Disability: Findings From a Two-Year Longitudinal Study

OBJECTIVE

To investigate the predictive power of resilience and vulnerability factors in relation to pain-related disability.

DESIGN

A two-year prospective study investigated whether back pain-related disability was predicted by the following variables, measured when pain was acute: 1) pain-related disability, 2) pain intensity, 3) depression, 4) fear avoidance beliefs, 5) anxiety sensitivity, and 6) resilience.

METHODS

Two hundred thirty-two patients treated in five primary care centers participated in this study. They were assessed at baseline during an acute back pain episode and at six, 12, 18, and 24 months. Ninety-nine patients completed all the assessment sessions. Linear mixed models were used to examine the trajectory of disability across the measurement occasions and its association with the predictors.

RESULTS

Individuals who had higher scores of disability and pain intensity when pain was acute also had higher scores of disability six months later; moreover, the increase in disability was greater over time in comparison with individuals with lower scores in disability and pain intensity when pain was acute. Individuals who had reported greater levels of fear avoidance beliefs when pain was acute also reported greater scores of disability six months later; however, no differences were found in the rate of change in disability. No associations were found between initial disability or rate of change and resilience, anxiety sensitivity, or depression.

CONCLUSIONS

Patients with acute back pain who show high levels of pain-related disability, pain intensity, and fear avoidance beliefs are at risk of developing back pain-related disability and should be the target of a preventive intervention.

New evidence for a pain personality? A critical review of the last 120 years of pain and personality

BACKGROUND

Personality traits may influence development and adjustment to ongoing pain. Over the past 120 years, there has been considerable research into the relationship between pain and personality. This paper presents new evidence for common personality traits found amongst chronic pain sufferers. In particular, it evaluates evidence for Cloninger's biopsychosocial model of personality in distinguishing typical personality features of chronic pain sufferers. It evaluates this evidence in the context of the past 120 years of research including psychodynamic formulations, MMPI studies, personality disorder investigations, and the influence of neuroticism on chronic pain.

METHODS

A literature search was conducted using PubMed, Medline, PsycINFO, SCOPUS and Cochrane library. Search terms included chronic pain, pain, personality, neuroticism, harm avoidance, self-directedness, attachment, Temperament and Character Inventory (TCI-R), MMPI, MMPI-2, NEO-PI, EPI, Millon Clinical Multiaxial Inventory, Millon Behavioral Health Inventory, Millon Behavioral Medicine Diagnostic, the Personality Assessment Inventory, the Locus of Control Construct and different combinations of these terms.

CONCLUSIONS

Recent descriptive studies using Cloninger's Temperament and Character Inventory (TCI-R) suggest that higher harm avoidance and lower self-directedness may be the most distinguishing personality features of chronic pain sufferers. High harm avoidance refers to a tendency to be fearful, pessimistic, sensitive to criticism, and requiring high levels of re-assurance. Low self-directedness often manifests as difficulty with defining and setting meaningful goals, low motivation, and problems with adaptive coping. Evidence for this personality profile is found across a wide variety of chronic pain conditions including fibromyalgia, headache and migraine, temporomandibular disorder, trigeminal neuropathy, musculo-skeletal disorders and heterogeneous pain groups. Limitations are also discussed. For example, high harm avoidance is also found in those suffering anxiety and depression. While many studies control for such factors, some do not and thus future research should address such confounds carefully. The evidence is also evaluated within the context of past research into the existence of 'a pain personality'. Psychodynamic formulations are found to be deficient in objective scientific methods. MMPI studies lack sufficient evidence to support 'a pain personality' and may be confounded by somatic items in the instrument. More recent neuroticism studies suggest a relationship between neuroticism and pain, particularly for adjustment to chronic pain. Personality disorders are more prevalent in chronic pain populations than non-pain samples.

CLINICAL IMPLICATIONS

Because harm avoidance reflects a tendency to developed conditioned fear responses, we suggest that higher harm avoidance may create more vulnerability to developing a fear-avoidance response to chronic pain. Furthermore, lower self-directedness may contribute to keeping a sufferer within this vicious cycle of fear, avoidance and suffering. Moreover, we suggest that harm avoidance and self-directedness are broader and more complex constructs than current clinical targets of CBT such as fear-avoidance and self-efficacy. Thus, assessing such personality traits may help to address the complexity of chronic pain presentations. For example, it may help to identify and treat sufferers more resistant to treatment, more prone to comorbidity and more vulnerable to entering the vicious cycle of chronic pain, suffering and disability.

Occupational-related back pain among Jordanian nurses: A descriptive study

Back pain is the leading cause of disability, decreased physical performance at work and absenteeism. Activities leading to the occurrence of back pain include patient transfer and long standing hours. This study aimed to explore the prevalence and determine the activities responsible for the presence of back pain among Jordanian nurses. A descriptive cross-sectional study was conducted on a convenience sample of nurses from governmental hospitals in Jordan. A self-report questionnaire was developed by Stubbs et al. and Harber et al. A descriptive method using mean, standard deviations and percentages was used, in addition to chi-square tests. Baseline findings indicated that more than three-quarters of the nurses studied suffered back pain during their work. Among nurses with back pain, about a fifth of them reported it to administration. The highest percentage of back pain was among critical care nurses. Further, the static factors contributed less commonly to back pain compared with the dynamic factors. Nearly half the participants with back pain reported taking days off more frequently. Jordanian nurses demonstrated one of the highest frequencies of back pain compared with other studies. Focus should be placed on education programmes about the appropriate body mechanics.

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.

Development of the Tampa Scale of Kinesiophobia for Parkinson's disease: confirmatory factor analysis, reliability, validity and sensitivity to change

The aim of this study was to validate the Tampa Scale of Kinesiophobia for Parkinson's disease (TSK-PD). This was a cross-sectional evaluation of the psychometric properties of an adapted questionnaire. The psychometric testing included confirmatory factor analysis, reliability by internal consistency (Cronbach's α) and test-retest reliability (intraclass correlation coefficient), construct validity by comparing TSK-PD with the Falls Efficacy Scale-International (FES-I), the Movement Disorder Society - Unified Parkinson's Disease Rating Scale (MDS-UPDRS), the Hospital Anxiety and Depression Score (HADS) and the Short-Form Health Survey (SF-36) (Pearson's correlations), and sensitivity to change by calculating the smallest detectable change. The questionnaire was administered to 132 patients with Parkinson's disease. Factor analysis confirmed a two-factor (harm and activity avoidance), 13-item solution, which led to an acceptable data-model fit. Internal consistency (α=0.94) and test-retest reliability (intraclass correlation coefficient, model 2.1=0.90) were good. Construct validity showed a close correlation between the TSK-PD and FES-I (r=-0.710); a moderate correlation with the MDS-UPDRS (r=0.513); moderate to close correlations with HADS-D (r=0.443) and HADS-A (r=0.626); moderate correlations with the mental subscales of the SF-36 (r=-0.327 to -0.563); and poor correlations with the physical subscales of the SF-36 (r=-0.236 to -0.248). The smallest detectable change was 11. The TSK-PD had a good factorial structure and satisfactory psychometric properties. Its use is recommended for clinical and research purposes.

Reduction in sick leave by a workplace educational low back pain intervention: A cluster randomized controlled trial

Aims: The aim of this study was to investigate whether a workplace educational low back pain intervention had an effect on sick leave at the individual level and to identify possible predictors of the effect of intervention. Methods: Work units in two municipalities were cluster randomized to (a) educational meetings and peer support (45 units), (b) educational meetings, peer support and access to an outpatient clinic if needed (48 units) or (c) a control group (42 units). Both intervention groups attended educational meetings with information about back pain based on a non-injury model. A peer adviser was selected from among their colleagues. The outcome was days of sick leave at the individual level at 3, 6, 9 and 12 months, adjusting for previous sick leave at the unit level. As a result of similar effects on sick leave, the two intervention groups were merged (n=646) and compared with the control group (n=211). The predictors were different levels of belief in back pain myths, pain-related fear, helplessness/hopelessness and low back pain. Results: The intervention group had significantly less days of sick leave at the three month (4.9 days, p=0.001) and six month (4.4 days, p=0.016) follow ups compared with the control group. At three months, a low level of pain-related fear was the only predictor for the intervention effect (8.0 less days of sick leave, p<0.001). Conclusions: A workplace educational back pain intervention had an effect on sick leave for up to six months. A low score on pain-related fear was a predictor of the intervention effect.

A multi-faceted workplace intervention targeting low back pain was effective for physical work demands and maladaptive pain behaviours, but not for work ability and sickness absence: Stepped wedge cluster randomised trial

Aims: The aims of this study were to test whether a multi-faceted intervention effective for low back pain was effective for physical capacity, work demands, maladaptive pain behaviours, work ability and sickness absence due to low back pain. Methods: A stepped wedge cluster randomised, controlled trial with 594 nurses’ aides was conducted. The intervention lasted 12 weeks and consisted of physical training (12 sessions), cognitive behavioural training (two sessions) and participatory ergonomics (five sessions). Occupational lifting, fear avoidance, physical exertion, muscle strength, support from management, work ability and sickness absence due to low back pain were measured every 3 months. Before and after the intervention we measured physical capacity, kinesiophobia and need for recovery. Linear mixed models adjusted for baseline values of the outcome were used to estimate the effect. Results: Significant reduction in occupational lifting (–0.35 (95% confidence interval −0.61 to −0.08)), and improvement in two measures of fear avoidance ((–0.75 (95% confidence interval −1.05 to −0.45) and −0.45 (95% confidence interval −0.80 to −0.11)) were found for the intervention group compared to the control. There were no significant effects on physical exertion, muscle strength, support from management, work ability or sickness absence due to low back pain. After the intervention, significant increased physical capacity and improvements in kinesiophobia were found, but no change in need for recovery. Conclusions: The intervention was significantly effective for physical work demands and maladaptive pain behaviours, but not for work ability and sickness absence due to low back pain. To improve work ability or reduce sickness absence due to low back pain more specific interventions should probably be developed.

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.

Is exposure in vivo cost-effective for chronic low back pain? A trial-based economic evaluation

Background

Back pain is one of the most expensive health complaints. Comparing the economic aspects of back pain interventions may therefore contribute to a more efficient use of available resources. This study reports on a long-term cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) of two treatments as viewed from a societal perspective: 1) exposure in vivo treatment (EXP), a recently developed cognitive behavioral treatment for patients with chronic low back pain who have elevated pain-related fear and 2) the more commonly used graded activity (GA) treatment.

Methods

Sixty-two patients with non-specific chronic low back pain received either EXP or GA. Primary data were collected at four participating treatment centers in the Netherlands. Primary outcomes were self-reported disability (for the CEA) and quality-adjusted life years (for the CUA). Program costs, health care utilization, patient and family costs, and production losses were measured by analyzing therapy records and cost diaries. Data was gathered before, during, and after treatment, and at 6 and 12 months after treatment. Non-parametric bootstrap analyses were used to quantify the uncertainty concerning the cost-effectiveness ratio. In addition, cost-effectiveness planes and cost-effectiveness acceptability curves were performed.

Results

EXP showed a tendency to reduce disability, increase quality adjusted life years and decrease costs compared to GA. The incremental cost-effectiveness ratios of both the CEA and CUA are in favor of EXP.

Conclusions

Based on these results, implementing EXP for this group of patients seems to be the best decision.

Trial registration

ISRCTN88087718

Spanish Version of the Avoidance-Endurance Questionnaire: Factor Structure and Psychometric Properties

To analyze the factorial structure and psychometric properties of the Spanish adaptation of the AEQ, and to validate it by reporting relevant pain-related variables, which were not investigated in the original study. One hundred and fifty Spanish patients diagnosed with chronic back and neck pain were referred by physicians from different pain clinics in Spain; all the patients filled out the questionnaires at their clinic. A series of principal components analyses (PCA) was performed to develop the Spanish version of the AEQ. Reliability and validity were also calculated. The PCAs revealed five fear-avoidance scales (Kaiser-Meyer-Olkin measures were between .60 and .88, and Bartlett's tests were significant, p .73) and suitable validity (p < .05). New results associated with pain-related cognitive/affective and behavioural responses are discussed. This instrument will probably help clinicians to identify Spanish patients at a high risk of chronicity and to develop treatments tailored to the different profiles in order to improve secondary and tertiary prevention in back and neck pain.

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.

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.

Low back pain beliefs are associated to age, location of work, education and pain-related disability in Chinese healthcare professionals working in China: a cross sectional survey

Background

Low back pain (LBP) is the leading cause of disability worldwide. Evidence pointing towards a more efficacious model of care using a biopsychosocial approach for LBP management highlights the need to understand the pain-related beliefs of patients and those who treat them. The beliefs held by healthcare professionals (HCPs) are known to influence the treatment advice given to patients and consequently management outcomes. Back pain beliefs are known to be influenced by factors such as culture, education, health literacy, place of work, personal experience of LBP and the sequelae of LBP such as disability. There is currently a knowledge gap among these relationships in non-western countries. The aim of this study was to examine the associations between LBP-related beliefs among Chinese HCPs and characteristics of these HCPs.

Methods

A convenience sample of 432 HCPs working in various health settings in Shanghai, China, completed a series of questionnaires assessing their demographic characteristics, LBP status, pain-related disability and their beliefs about their own LBP experience, using the Back beliefs Questionnaire (BBQ) and the Fear Avoidance Beliefs Questionnaire (FABQ).

Results

Younger Chinese HCPs (20–29 years) held more negative beliefs and attitudes related to LBP compared to older HCPs (>40years; BBQ mean difference [95% CI]: 2.4 [0.9 - 3.9], p = 0.001). HCPs working outside tertiary hospitals had poorer beliefs concerning the inevitable consequences of LBP (BBQ mean difference [95% CI]: −2.4 [−3.8 - −1.0], p = 0.001). HCPs who experienced LBP had higher level of fear avoidance beliefs when experiencing high LBP-related disability (FABQ-physical mean difference [95% CI]: 2.8 [1.5 - 4.1], p < 0.001; FABQ-work mean difference [95% CI]: 6.2 [4.0 - 8.4], p < 0.001)) and had lower level of fear avoidance beliefs if they had completed postgraduate study (FABQ-physical mean difference [95% CI]: 2.9 [−5.8 - 0.0], p = 0.049).

Conclusion

This study suggests that LBP-related beliefs and attitudes among Chinese HCPs are influenced by age, location of work, level of LBP-related disability and education level. Understanding back pain beliefs of Chinese HCPs forms an important foundation for future studies into the condition and its management in China.

Prevention of low back pain and its consequences among nurses' aides in elderly care: a stepped-wedge multi-faceted cluster-randomized controlled trial

BACKGROUND

A high prevalence of low back pain has persisted over the years despite extensive primary prevention initiatives among nurses' aides. Many single-faceted interventions addressing just one aspect of low back pain have been carried out at workplaces, but with low success rate. This may be due to the multi-factorial origin of low back pain. Participatory ergonomics, cognitive behavioral training and physical training have previously shown promising effects on prevention and rehabilitation of low back pain. Therefore, the main aim of this study is to examine whether a multi-faceted workplace intervention consisting of participatory ergonomics, physical training and cognitive behavioral training can prevent low back pain and its consequences among nurses' aides. External resources for the participating workplace and a strong commitment from the management and the organization support the intervention.

METHODS/DESIGN

To overcome implementation barriers within usual randomized controlled trial designed workplace interventions, this study uses a stepped-wedge cluster-randomized controlled trial design with 4 groups. The intervention is delivered to the groups at random along four successive time periods three months apart. The intervention lasts three months and integrates participatory ergonomics, physical training and cognitive behavioral training tailored to the target group. Local physiotherapists and occupational therapists conduct the intervention after having received standardized training. Primary outcomes are low back pain and its consequences measured monthly by text messages up to three months after initiation of the intervention.

DISCUSSION

Intervention effectiveness trials for preventing low back pain and its consequences in workplaces with physically demanding work are few, primarily single-faceted, with strict adherence to a traditional randomized controlled trial design that may hamper implementation and compliance, and have mostly been unsuccessful. By using a stepped wedge design, and obtain high management commitment and support we intend to improve implementation and aim to establish the effectiveness of a multi-faceted intervention to prevent low back pain. This study will potentially provide knowledge of prevention of low back pain and its consequences among nurses' aides. Results are expected to be published in 2015-2016.

TRIAL REGISTRATION

The study is registered as ISRCTN78113519.

Absence from work and return to work in people with back pain: a systematic review and meta-analysis

Background

A considerable proportion of work absence is attributed to back pain, however prospective studies in working populations with back pain are variable in setting and design, and a quantitative summary of current evidence is lacking.

Objective

To investigate the extent to which differences in setting, country, sampling procedures and methods for data collection are responsible for variation in estimates of work absence and return to work.

Methods

Systematic searches of seven bibliographic databases. Inclusion criteria were: adults in paid employment, with back pain, work absence or return to work during follow-up had been reported. Random effects meta-analysis and meta-regression analysis was carried out to provide summary estimates of work absence and return to work rates.

Results

45 studies were identified for inclusion in the review; 34 were included in the meta-analysis. The pooled estimate for the occurrence of work absence in workers with back pain was 15.5% (95% CI 9.8% to 23.6%, n=17 studies, I² 98.1%) in studies with follow-up periods of ≤6 months. The pooled estimate for the proportion of people with back pain returning to work was 68.2% (95% CI 54.8% to 79.1%, n=13, I² 99.2%), 85.6% (95% CI 78.2% to 90.7%, n=13, I² 98.7%) and 93.3% (95% CI 84.0% to 94.7%, n=10, I² 99%), at 1 month, 1–6 months and ≥6 months, respectively. Differences in setting, risk of participation bias and method of assessing work absence explained some of the heterogeneity.

Conclusions

Pooled estimates suggest high return to work rates, with wide variation in estimates of return to work only partly explained by a priori defined study-level variables. The estimated 32% not back at work at 1 month are at a crucial point for intervention to prevent long term work absence.

Effects of noxious stimulation and pain expectations on neuromuscular control of the spine in patients with chronic low back pain

BACKGROUND CONTEXT

Alterations of the neuromuscular control of the lumbar spine have been reported in patients with chronic low back pain (LBP). During trunk flexion and extension tasks, the reduced myoelectric activity of the low back extensor musculature observed during full trunk flexion is typically absent in patients with chronic LBP.

PURPOSE

To determine whether pain expectations could modulate neuromuscular responses to experimental LBP to a higher extent in patients with chronic LBP compared with controls.

STUDY DESIGN

A cross-sectional, case-control study.

PATIENT SAMPLE

Twenty-two patients with nonspecific chronic LBP and 22 age- and sex-matched control participants.

METHODS

Trunk flexion-extension tasks were performed under three experimental conditions: innocuous heat, noxious stimulation with low pain expectation, and noxious stimulation with high pain expectation. Noxious stimulations were delivered using a contact heat thermode applied on the skin of the lumbar region (L4-L5), whereas low or high pain expectations were induced by verbal and visual instructions.

OUTCOME MEASURES

Surface electromyography of erector spinae at L2-L3 and L4-L5, as well as lumbopelvic kinematic variables were collected during the tasks. Pain was evaluated using a numerical rating scale. Pain catastrophizing, disability, anxiety, and fear-avoidance beliefs were measured using validated questionnaires.

RESULTS

Two-way mixed analysis of variance revealed that pain was significantly different among the three experimental conditions (F2,84=317.5; p<.001). Increased myoelectric activity of the low back extensor musculature during full trunk flexion was observed in the high compared with low pain expectations condition at the L2-L3 level (F2,84=9.5; p<.001) and at the L4-L5 level (F2,84=3.7; p=.030). At the L4-L5 level, this effect was significantly more pronounced for the control participants compared with patients with chronic LBP (F2,84=3.4; p=.045). Pearson correlation analysis revealed that increased lumbar muscle activity in full flexion induced by expectations was associated with higher pain catastrophizing in patients with chronic LBP (r=0.54; p=.012).

CONCLUSIONS

Repeated exposure to pain appears to generate rigid and less variable patterns of muscle activation in patients with chronic LBP, which attenuate their response to pain expectations. Patients with high levels of pain catastrophizing show higher myoelectric activity of lumbar muscles in full flexion and exhibit greater neuromechanical changes when expecting strong pain.

A Health- and Resource-Oriented Perspective on NSLBP

Nonspecific low back pain (NSLBP) is an important health issue of our time. Personal as well as economic factors, like suffering pain and experiencing disability on the one hand and enormous and still increasing costs to the economy and society on the other hand, display the importance of the matter. Tremendous research has been conducted in the last few decades on NSLBP. A PubMed search (June 17, 2013) on “low back pain” provided 22,980 hits, and when specifying for “low back pain, systematic review,” 3,134 hits were still generated. Most research has been done examining the development, risk factors, or therapeutic measures of NSLBP, but hardly any literature exists on resources related to NSLBP. The aims of this review are twofold. In order to shade light on the salutogenetic approach of NSLBP, and thus to focus on health instead of illness, the first aim is to facilitate the understanding of which therapeutic measures enhance the ability to cope with chronic NSLBP and enable (more) normal functioning in life. The second aim is to stimulate the understanding of resources protecting against the onset of NSLBP or against the development of chronic NSLBP and its resulting work absence.

Neuromuscular exercise and counseling decrease absenteeism due to low back pain in young conscripts: a randomized, population-based primary prevention study

STUDY DESIGN

Controlled intervention with group randomization.

OBJECTIVE

To investigate the effectiveness of a 6-month neuromuscular exercise and counseling program for reducing the incidence of low back pain (LBP) and disability in young conscripts, with a healthy back at the beginning of their compulsory military service.

SUMMARY OF BACKGROUND DATA

Basic military training is physically demanding on the back and requires adequate physical fitness. LBP causes significant morbidity and absence from military service.

METHODS

Participants were conscripts of 4 successive age cohorts (n = 1409). In the prestudy year, before adoption of the intervention, 2 successive cohorts of conscripts of 4 companies (n = 719) were followed prospectively for 6 months to study the baseline incidence of different categories of LBP. In the intervention year, conscripts (n = 690) of 2 new cohorts of the same companies (intervention group: antitank, engineer; control group: signal, mortar) were followed for 6 months. The intervention program aimed to improve conscripts' control of their lumbar neutral zone and specifically to avoid full lumbar flexion in all daily tasks.

RESULTS

Total number and incidence of off-duty days due to LBP were significantly decreased in the intervention companies compared with controls (adjusted hazard ratio = 0.42, 95% confidence interval = 0.18-0.94, P = 0.035). The number of LBP cases, number of health clinic visits due to LBP, and number of the most severe cases showed a similar decreasing trend but without statistical significance.

CONCLUSION

These findings provide evidence that exercise and education to improve control of the lumbar neutral zone have a prophylactic effect on LPB-related off-duty service days in the military environment when implemented as part of military service among young healthy men.

Fear-avoidance model of chronic pain: the next generation

OBJECTIVE

The fear-avoidance (FA) model of chronic pain describes how individuals experiencing acute pain may become trapped into a vicious circle of chronic disability and suffering. We propose to extend the FA model by adopting a motivational perspective on chronic pain and disability.

METHODS

A narrative review.

RESULTS

There is ample evidence to support the validity of the FA model as originally formulated. There are, however, some key challenges that call for a next generation of the FA model. First, the FA model has its roots in psychopathology, and investigators will have to find a way to account for findings that do not easily fit within such framework. Second, the FA model needs to address the dynamics and complexities of disability and functional recovery. Third, the FA model should incorporate the idea that pain-related fear and avoidance occurs in a context of multiple and often competing personal goals.

DISCUSSION

To address these 3 key challenges, we argue that the next generation of the FA model needs to more explicitly adopt a motivational perspective, one that is built around the organizing powers of goals and self-regulatory processes. Using this framework, the FA model is recast as capturing the persistent but futile attempts to solve pain-related problems to protect and restore life goals.

The acquisition and generalization of cued and contextual pain-related fear: an experimental study using a voluntary movement paradigm

Recent evidence indicates that pain-related fear can be acquired through associative learning. In the clinic, however, spreading of fear and avoidance is observed beyond movements/activities that were associated with pain during the original pain episode. One mechanism accounting for this spreading of fear is stimulus generalization. In a voluntary movement-conditioning paradigm, healthy participants received predictable pain (ie, one movement predicts pain, another does not) in one context, and unpredictable pain in another context. The former procedure is known to induce cued pain-related fear to the painful movement, whereas the latter procedure generates contextual pain-related fear. In both experimental pain contexts, we subsequently tested fear generalization to novel movements (having either proprioceptive features in common with the original painful movement or nonpainful movement). Results indicated that in the predictable pain context, pain-related fear spreads selectively to novel movements proprioceptively related to the original painful movement, and not to those resembling the original nonpainful movement. In the unpredictable context, nondifferential fear generalization was observed, suggesting persistent contextual pain-related fear and poor safety learning. These data illustrate that spreading of pain-related fear is fostered by previously acquired movement-pain contingencies. Based on recent advances in anxiety research, we proposed an innovative approach conceptualizing predictable pain as a laboratory model for fear of movement in regional musculoskeletal pain, and unpredictable pain generating contextual pain-related fear as a prototype of widespread musculoskeletal pain. Consequently, fear generalization might play an important role in spreading of pain-related fear and avoidance behavior in regional and widespread musculoskeletal pain.