Avoidance, pacing, or persistence in multidisciplinary functional rehabilitation for chronic musculoskeletal pain: An observational study with cross-sectional and longitudinal analyses

Relationship between pain activity patterns, and physical and psychological aspects and sleep quality in women with migraine

Migraine can cause different pain activity patterns. This cross-sectional study examines the relationship between pain activity patterns and physical and psychological aspects and sleep quality in women with migraine. Women diagnosed with migraine (n = 129) were reached through social media and announcements. Outcome measures were Pattern of Activity Measure-Pain (POAM-P) (avoidance, overdoing, pacing), Migraine Disability Assessment Scale (MIDAS), International Physical Activity Questionnaire-Short Form (IPAQ-SF), Depression Anxiety Stress Scale-21 (DASS-21), the Pittsburgh Sleep Quality Index (PSQI). While there was a negative correlation between the POAMP-avoidance and the IPAQ-SF rho = -0.178), there were positive correlations between the POAMP-avoidance and the MIDAS (rho = 0.454), the DASS-21-depression (rho = 0.413), the DASS-21-anxiety (rho = 0.321), and the DASS-21-stress (rho = 0.446). There were positive correlations between the POAMP-overdoing, and the DASS-21-depression (rho = 0.229), the DASS-21-stress (rho = 0.207), and the PSQI (rho = 0.217). There were also positive correlations between the POAMP-pacing and the MIDAS (rho = 0.283), the DASS-21-depression (rho = 0.250), and the DASS-21-anxiety (rho = 0.213) (p < .05). Pain activity patterns in women with migraines were associated with their disability, physical activity, psychological state, and sleep quality. Determining treatment based on pain activity patterns can improve migraine treatment outcomes.

Physical activity based on daily steps in patients with chronic musculoskeletal pain: evolution and associated factors

BACKGROUND

People with chronic musculoskeletal pain (CMSP) often have low physical activity. Various factors can influence the activity level. The aim of this study was to monitor physical activity, assessed by the number of steps per day, over time in people with CMSP and identify factors that could be associated with this activity feature.

METHODS

This prospective study involved people undergoing rehabilitation following an orthopedic trauma that had led to CMSP. At entry, participants completed self-reported questionnaires assessing pain, anxiety, depression, catastrophyzing, kinesiophobia, and behavioural activity patterns (avoidance, pacing and overdoing). They also underwent functional tests, assessing walking endurance and physical fitness. To determine daily step counts, participants wore an accelerometer for 1 week during rehabilitation and 3 months post-rehabilitation. The number of steps per day was compared among three time points: weekend of rehabilitation (an estimate of pre-rehabilitation activity; T1), weekdays of rehabilitation (T2), and post-rehabilitation (T3). Linear regression models were used to analyze the association between daily steps at T2 and at T3 and self-reported and performance-based parameters.

RESULTS

Data from 145 participants were analyzed. The mean number of steps was significantly higher during T2 than T1 and T3 (7323 [3047] vs. 4782 [2689], p < 0.001, Cohen's d = 0.769, and 4757 [2680], p < 0.001, Cohen's d = 0.693), whereas T1 and T3 results were similar (p = 0.92, Cohen's d = 0.008). Correlations of number of steps per day among time points were low (r ≤ 0.4). Multivariable regression models revealed an association between daily steps at T2 and pain interfering with walking, anxiety and overdoing behaviour. Daily steps at T3 were associated with overdoing behaviour and physical fitness.

CONCLUSIONS

Despite chronic pain, people in rehabilitation after an orthopedic trauma increased their physical activity if they were given incentives to do so. When these incentives disappeared, most people returned to their previous activity levels. A multimodal follow-up approach could include both therapeutic and environmental incentives to help maintain physical activity in this population.

Beyond activity patterns: The complex process of activity management among individuals with chronic musculoskeletal pain after an orthopaedic trauma

CONTEXT

Individuals must change the way they perform activities in response to chronic pain. In the literature, three activity patterns are commonly described: avoidance, pacing, and persistence. Many studies have explored these activity patterns. However, little research has delved into the factors that lead people to adopt a particular activity behaviour. This study aimed to explore the relationship that people with chronic musculoskeletal pain have with activity and highlight the factors underlying their practices.

METHODS

The qualitative study was conducted by researchers in the social sciences, physiotherapy, psychology, and rehabilitation medicine. Observations of vocational workshops and semi-structured interviews were conducted with 33 persons undergoing rehabilitation for chronic musculoskeletal pain after an accident.

RESULTS

Patients' declarations and actions show that any one patient will alternate between activity patterns: the same person may adopt a strategy of avoidance, pacing or persistence depending on the context, the importance of the activity, personal objectives, and representations of self, pain, and activity. The decision to engage in a particular behaviour is based on a process of self-negotiation weighted by the circumstances, the nature of the activity, the importance attached to it, and the individual's perceived ability.

CONCLUSION

Our study emphasized the complexity of physical, social, and contextual factors that intervene in the relationship toward activity. Rather than favouring pacing, the therapist's role in rehabilitation might be to reinforce the reflexive process and the patient's adaptability in approaching the activity, to foster the capacity to find flexible solutions.

SIGNIFICANCE

Patients choose an activity pattern (avoidance, pacing, persistence) according to the challenges they face in their daily lives. Context, representations of self and activity, as well as goals sought influence these choices. Some patients report having learned to adapt their activity management strategies. Therefore, therapeutic approaches in the rehabilitation context could focus on these adaptive capacities to offer patients optimal pain and activity management and develop their ability to use different strategies according to the circumstance.

How to Promote Walking in Women with Fibromyalgia: A Look at Catastrophizing, Goal Conflict, and Avoidance from a Self-Emotional Regulatory Perspective

The aim of this study was twofold: to explore the concordance between two measures of physical activity (accelerometer and IPAQ) among female fibromyalgia (FM) patients, as well as to examine the impact of psychosocial variables (catastrophism, activity avoidance) on walking among these patients. Helplessness, activity avoidance, and commitment to physical activity were evaluated in 132 FM women. After the first assessment, an accelerometer was placed by a psychologist on each participant for seven consecutive days. Eight days later, accelerometers were collected, and participants were evaluated again using the IPAQ. Two models were tested to analyze mediation and a moderated mediation effect. The mediating role of activity avoidance between helplessness and minutes walked was corroborated regarding the objective measure of walking. The effect of helplessness on minutes walked during a week was mediated by activity avoidance and assessed by accelerometers. Cognitive variables played a contextual role when trying to promote exercise. Activity avoidance must be understood as a key variable in physical activity promotion, specifically in the promotion of walking with the aim to do exercise in individuals with FM.

Clinimetric Properties of the Steep Ramp Test to Assess Cardiorespiratory Fitness, Its Underlying Physiological Responses, and Its Current Applications: A Scoping Review

OBJECTIVE

Providing an overview of the clinimetric properties of the steep ramp test (SRT)-a short-term maximal exercise test-to assess cardiorespiratory fitness (CRF), describing its underlying physiological responses, and summarizing its applications in current clinical and research practice.

DATA SOURCES

MEDLINE (through PubMed), CINAHL Complete, Cochrane Library, EMBASE, and PsycINFO were searched for studies published up to July 2023, using keywords for SRT and CRF.

STUDY SELECTION

Eligible studies involved the SRT as research subject or measurement instrument and were available as full text articles in English or Dutch.

DATA EXTRACTION

Two independent assessors performed data extraction. Data addressing clinimetric properties, physiological responses, and applications of the SRT were tabulated.

DATA SYNTHESIS

In total, 370 studies were found, of which 39 were included in this study. In several healthy and patient populations, correlation coefficients between the work rate at peak exercise (WRpeak) attained at the SRT and oxygen uptake at peak exercise during cardiopulmonary exercise testing (CPET) ranged from .771-.958 (criterion validity). Repeated measurements showed intraclass correlation coefficients ranging from .908-.996 for WRpeak attained with the first and second SRT (test-retest reliability). Physiological parameters, like heart rate and minute ventilation at peak exercise, indicated that the SRT puts a lower burden on the cardiopulmonary system compared to CPET. The SRT is mostly used to assess CRF, among others as part of preoperative risk assessment, and to personalize interval training intensity.

CONCLUSIONS

The SRT is a practical short-term maximal exercise test that is valid for CRF assessment and to monitor changes in CRF over time in various healthy and patient populations. Its clinimetric properties and potential applications make the SRT of interest for a widespread implementation of CRF assessment in clinical and research practice and for personalizing training intensity and monitoring longitudinal changes in CRF.

Using a Whole Health Approach to Build Biopsychosocial-Spiritual Personal Health Plans for Veterans with Chronic Pain

Chronic pain affects over 50 million Americans per year and costs society billions of dollars annually. It is widely accepted that the biomedical model is outdated and research on the biopsychosocial model of chronic pain has increased in recent years, concurrent with investigations into self-management of chronic pain. The Veterans Health Administration (VHA) has incorporated both of these approaches into their Whole Health System. This work describes the VHA Whole Health System, reviews the literature on alignment between the Whole Health System's Circle of Health and chronic pain, and explains how the VHA Whole Health model may be used as a method for organizing self-management strategies within a personal health plan in the context of chronic pain. Given the infusion of nurses throughout the healthcare system, nurses are in a unique position to champion this biopsychosocial-spiritual approach to care.

Should we separately measure the pain parameter of the Constant-Murley score in patients with chronic shoulder pain?

BACKGROUND

The Constant-Murley Score (CMS) is a relatively unique shoulder assessment tool because it combines patient-reported outcomes (pain and activity), performance measurement and clinician-reported outcomes (strength and mobility). With these characteristics, the effect of patient-related psychological factors on the CMS remains debated. We aimed to investigate which parameters of the CMS are influenced by psychological factors by assessing the CMS before and after rehabilitation for chronic shoulder pain.

METHODS

This retrospective study screened all patients (18-65 years old) who were admitted for interdisciplinary rehabilitation for chronic shoulder pain (≥ 3 months) between May 2012 and December 2017. Patients with unilateral shoulder injuries were eligible. Exclusion criteria were shoulder instability, concomitant neurological injuries, complex regional pain syndrome (including Steinbrocker syndrome), heavy psychiatric issues, and missing data. The Hospital Anxiety and Depression Scale, Pain Catastrophizing scale, and Tampa Scale of Kinesiophobia were administered before and after treatment. Regression models were used to estimate associations between psychological factors and the CMS.

RESULTS

We included 433 patients (88% male, mean age 47±11 years) with a median duration of symptoms of 392.2 days (interquartile range: 266.5-583.5). Rotator cuff issue was present in 71% of patients. During interdisciplinary rehabilitation, patients were followed for a mean of 33.6±7.5 days. The mean CMS at entry was 42.8 ±15.5. The mean gain in CMS after treatment was 10.6 ±10.9. Before treatment, psychological factors were significantly associated with only the pain CMS parameter: -0.37 (95% CI: -0.46 to -0.28), p <0.001. After treatment, psychological factors were associated with the evolution of the four CMS parameters: -0.12 (-0.23 to -0.01) to -0.26 (95% CI: -0.36 to -0.16), p<0.05.

CONCLUSIONS

This study raises the question of a distinct assessment of pain when assessing shoulder function with CMS in patients with chronic shoulder pain. The separation of the "pain parameter" from the overall CMS score seems illusory with this tool that is used worldwide. However, clinicians should be aware that psychological factors can negatively influence the evolution of all CMS parameters during follow-up, which argues for a biopsychosocial approach to patients with chronic shoulder pain.

The Role of Self-Efficacy and Activity Patterns in the Physical Activity Levels of Women with Fibromyalgia

Keeping high levels of physical activity is a challenge among chronic patients. In this regard, self-efficacy has been identified as a crucial variable to reduce sedentarism and physical inactivity in women with fibromyalgia. The current study aimed to evaluate the associations among objective physical activity levels, self-efficacy, activity patterns, and the impact of the disease, as well as to compare those variables between women with fibromyalgia with different self-efficacy levels. For this purpose, in this cross-sectional study, the physical activity levels of 123 women with fibromyalgia were assessed by accelerometers, together with self-efficacy, the impact of the disease, and activity patterns. Results revealed that self-efficacy for light or moderate physical activity was directly related to light (p < 0.01), moderate (p < 0.01), and vigorous physical activity (p < 0.05), as well as inversely related to sedentary time (p < 0.01). Moreover, the main differences were observed between those with low self-efficacy levels and the rest of the sample, while there were no differences between the high and the medium self-efficacy groups (p > 0.05). Thus, self-efficacy for walking and light physical activity seems to be more relevant than self-efficacy for moderate and vigorous physical activity to achieve higher levels of physical activity.

The Relationship Between Pain Intensity and Pain-Related Activity Patterns in Older Adults with Chronic Musculoskeletal Pain: Mediating Roles of Pain Resilience and Pain Catastrophizing

Purpose

To explore the relationship between pain intensity, pain resilience, pain catastrophizing, and pain-related activity patterns in older adults with chronic musculoskeletal pain (CMP).

Patients and Methods

A total of 220 elderly Chinese with chronic musculoskeletal pain were recruited from a tertiary general hospital. Participants completed several measures including a demographic questionnaire, Brief Pain Inventory (BPI), Pain Resilience Scale (PRS), Pain Catastrophizing Scale (PCS), and Patterns of Activity Measure-Pain (POAM-P). Moreover, Process version 3.5 plug-in SPSS26 was used to test the mediation effect between variables.

Results

The scores of POAM-P in older adults with CMP from high to low were: avoidance (27.39 ± 8.10), pacing (24.25 ± 9.48), and overdoing (16.65 ± 10.95). Mediation analysis revealed that pain resilience and pain catastrophizing mediated the relationship between pain intensity and pain-related activity patterns (avoidance and pacing) in older adults with CMP.

Conclusion

These results provide evidence for the role of pain resilience and pain catastrophizing in the relationship between pain intensity and pain-related activity patterns. Interventions targeting these factors should be included in activity management programs for elderly CMP patients. It may be possible to reduce the negative impact of pain intensity on activity patterns by improving pain resilience and reducing pain catastrophizing.

The Influence of the Fear of Negative Evaluation on Activity Avoidance in Fibromyalgia: Exploring Pain Acceptance and Positive Affect as Resilience Variables

To examine the mediating role of pain acceptance (PAcc) between fear of negative evaluation (FNE) and activity avoidance (AV) at different levels of positive affect (PA) (moderator) among women diagnosed with fibromyalgia (FM) (moderate mediation model). This study was cross-sectional in design. A convenience sample of women with FM (n = 231) completed measures of pain severity, FNE, PAcc, AV, and PA. A simple mediation model and a moderate mediation model was constructed and analyzed using the SPSS macro-PROCESS. First, PAcc mediated the effect of FNE on AV (β = .02, SE = 0.008; [95% CI [0.0075, 0.0394]). Second, a mediated effect of PAcc between FNE and AV moderated by PA at medium and high levels of PA were found (m: 0.23; β = -.22, p = .0006; h: 9.59; β = -.34, p = .0002. Future work should seek to validate study findings in diverse samples of FM patients. Additionally, future work should explore how FM self-management interventions that include PAcc can promote increased activity among women suffering from FM with medium to high levels of PA.

Validation of the Japanese version of the patterns of activity measure-pain in individuals with chronic pain

Background

The Patterns of Activity Measure-Pain (POAM-P) is a self-report questionnaire that measures avoidance, overdoing, and pacing in individuals with chronic pain. We aimed to develop and confirm the psychometric properties of the Japanese version of the POAM-P(POAM-P-J) in Japanese individuals with chronic pain.

Methods

We recruited 147 Japanese individuals with chronic pain (106 women; mean age 64.89 ± 12.13 years). The individuals completed the POAM-P-J, the Brief Pain Inventory (BPI), and the Hospital Anxiety and Depression Scale (HADS). The following psychometric properties of the POAM-P-J were confirmed: structural validity, internal consistency, test–retest reliability, and concurrent validity.

Results

We tested factor structure via confirmatory factor analyses (CFA). We chose the 3-factor model with six covariances. The POAM-P-J’s internal consistency and test–retest reliability were acceptable to good (α = 0.79–0.86; ICC = 0.72–0.87). The avoidance and overdoing subscales were positively associated with pain severity, pain interference, and anxiety measures (all p < 0.05), but the pacing subscale was not significantly associated with these pain-related measures.

Conclusions

Although the structural validity of the POAM-P-J remains questionable, its internal consistency, test–retest reliability, and concurrent validity were confirmed. The POAM-P-J is useful in both research and clinical practice for evaluating the activity patterns of Japanese patients with chronic pain.

Development and Initial Evaluation of the Patterns of Activity Measure-Pain Short Form

OBJECTIVES

There has been growing interest in examining pain-related activity patterns and their relationships to psychosocial functioning. The Patterns of Activity Measure-Pain (POAM-P) is frequently used to measure 3 pain-related activity patterns: avoidance, overdoing, and pacing. Although the POAM-P possesses excellent psychometric properties, its length may limit its utility where multiple measures of functioning are required or the time available for assessment is limited. The present studies describe the development and evaluation of a short-form version of this measure.

MATERIALS AND METHODS

In Study 1, 775 individuals with ongoing pain completed the original POAM-P at the start of a treatment program. Item analyses were conducted to construct a short-form of the POAM-P. In Study 2, a separate sample of 171 individuals completed the original and short-form of the POAM-P, and measures of psychosocial functioning. Correlations between the short-form and original, and between the short-form and measures of psychosocial functioning were examined to evaluate the reliability and validity of the short-form.

RESULTS

The 3 scales of the short-form were found to have excellent internal consistency and correlated well with corresponding scales on the original POAM-P. Correlations between scales on the short-form and measures of psychosocial functioning supported the construct validity of the measure.

DISCUSSION

The short-form of the POAM-P possesses good psychometric properties and correlates well with the long-form of the measure. It appears to be a promising addition to existing measures of pain-related activity. It may be useful as an addition to questionnaire batteries that comprehensively assess the psychosocial functioning of individuals with ongoing pain.

How to objectively assess and observe maladaptive pain behaviors in clinical rehabilitation: a systematic search and review

Background

Cognitive-affective factors influence the perception of pain and disability. These factors can lead to pain behaviors (PB) that can persist and become maladaptive. These maladaptive PB will further increase the risk of chronicity or persistence of symptoms and disability. Thus, clinicians must be prepared to recognize maladaptive PB in a clinical context. To date, in the context of assessment in a rehabilitation setting, PB in clinical settings are poorly documented. The main objective of this study was to identify direct observation methods and critically appraise them in order to propose recommendations for practice. As a secondary objective, we explored and extracted the different observable PB that patients could exhibit and that clinicians could observe.

Methods

We conducted a comprehensive review on four databases with a generic search strategy in order to obtain the largest range of PB. For the first objective, a two-step critical appraisal used clinical criteria (from qualitative studies on barriers to implement routine measures) and psychometric criteria (from Brink and Louw critical appraisal tool) to determine which observation methods could be recommended for clinical practice. For the second objective, we extracted PB found in the literature to list potential PB that patients could exhibit, and clinicians could observe.

Results

From the 3362 retrieved studies, 47 met the inclusion criteria for the first objective. The clinical criteria allowed us to select three observation methods. After the psychometric step, two observation methods were retained and recommended for clinical practice: the Behavioral Avoidance Test-Back Pain (BAT-Back) and the Pain Behaviour Scale (PaBS). For the second objective, 107 studies met the inclusion criteria. The extraction of the PB allowed us to list a large range of PB and classify the data in 7 categories of PB.

Conclusion

Our results allowed us to recommend two observation methods for clinical practice. However, these methods have limitations and are validated only in chronic low back pain populations. With the extraction of PB presented in the literature, we contribute to better prepare clinicians to recognize PB in all patients who are experiencing pain.

Activity Patterns and Functioning. A Contextual-Functional Approach to Pain Catastrophizing in Women with Fibromyalgia

Background: The psychological flexibility model states that activity patterns are not deemed to be intrinsically functional or dysfunctional; it is considered that underlying factors, such as personal goals and contextual factors, are what will determine their effects on disability. Pain catastrophizing has frequently been associated with several important pain-related outcomes. Despite its recent conceptualization within affective–motivational approaches, its moderating role between activity patterns and dysfunction has not been analyzed. Methods: This study analyzes the moderating role of pain catastrophizing and its dimensions (Pain Catastrophizing Scale) between activity patterns (Activity Patterns Scale) and disease impact (Fibromyalgia Impact Questionnaire—Revised) in 491 women with fibromyalgia. Results: Activity avoidance (p < 0.001), excessive persistence (p < 0.001) and pacing (p < 0.01) patterns were positively associated with fibromyalgia impact. Helplessness shows a moderating role between pain avoidance (B = 0.100, t =2.30, p = 0.021, [0.01, 0.18]), excessive persistence (B = −0.09, t = −2.24, p = 0.02, [−0.18, −0.01]), pain persistence (B = −0.10, t = −2.04, p = 0.04, [−0.19, −0.004]) and functioning. Conclusion: Helplessness (within pain catastrophizing) is a relevant variable within psychological flexibility models applied to activity patterns. Specifically, pain avoidance is especially dysfunctional in patients with high helplessness. To improve excessive persistence and pain persistence, it is necessary to reduce helplessness before regulating activity patterns.

Are Pacing Patterns Really Based on Value Goals? Exploring the Contextual Role of Pain Acceptance and Pain Catastrophizing in Women with Fibromyalgia

Pain catastrophizing and pain acceptance have been associated with functioning in fibromyalgia. In relation to activity patterns, pacing has been defined as a helpful pattern to regulate activities in the context of value-based goals, but results regarding whether it is adaptive or not are controversial. This study analyzes the moderating role of pain acceptance between pain catastrophizing and pacing in 231 women with fibromyalgia. Moderation analyses were conducted with model 1 from the PROCESS Macro version 3.4. The results showed a clear moderating effect of pain acceptance. At low levels of pain acceptance, catastrophizing and pacing patterns maintained significant and positive associations. However, at high levels of pain acceptance, pacing was independent of catastrophizing. Far from considering pacing patterns as functional or dysfunctional per se, our results suggest that women with low pain acceptance carry out pacing influenced by catastrophizing independently of their goal pursuit, while patients who accept their pain may use pacing as a regulatory mechanism according to their goals.

A scoping review to ascertain the parameters for an evidence synthesis of psychological interventions to improve work and wellbeing outcomes among employees with chronic pain

Background: Psychological interventions have mixed effects on improving employee outcomes, partly due to significant variability across studies and a lack of focus on mechanisms of action. This scoping review reports on the parameters of these interventions and examines intervention content to bring clarity to this heterogeneous topic area and direct future systematic review work.

Method: Six databases were searched (Cinahl, Cochrane, Embase, Medline, PsychINFO and Web of Science) from April 2010 to August 2020, and a grey literature search was undertaken. Screening was undertaken independently by two authors. The results summarised country, participant and employment characteristics, psychological interventions and work, health and wellbeing outcomes. 10% of the papers were analysed to determine the feasibility of coding intervention descriptions for theory and behaviour change technique (BCT) components.

Results: Database searches yielded 9341 titles, of which 91 studies were included. Most studies were conducted in Europe (78%) and included males and females (95%) ranging in age from 31-56.6 years although other demographic, and employment information was lacking. Musculoskeletal pain was common (87%). Psychological interventions commonly included cognitive behavioural therapy (30%) and education (28%). Most studies employed a randomised control trial design (64%). Over half contained a control group (54%). Interventions were delivered in mostly healthcare settings (72%) by health professionals. Multiple outcomes were often reported, many of which involved measuring sickness absence and return-to-work (62%) and pain and general health (53%). Within the feasibility analysis, most papers met the minimum criteria of containing one paragraph of intervention description, but none explicitly mentioned theory or BCTs.

Conclusion: Psychological interventions for employees with chronic pain vary in their nature and implementation. We have shown scoping reviews can be used to assess the feasibility of applying tools from health psychology to identify the content of these interventions in future systematic review work to improve intervention development.

Exploring the contextual role of pain severity as a moderator of the relationship between activity patterns and the physical and mental functioning of women with fibromyalgia

INTRODUCTION

In past years, and mostly due to contextual psychological therapies, it has been argued that particular behavioural patterns may be useful in certain contexts, but not in others. The goal of this study has been to explore whether pain severity is indeed a contextual factor influencing the relationship between two controversial activity patterns, namely pacing and persistence, and functionality in people with fibromyalgia.

METHODS

Participants were 231 women diagnosed with fibromyalgia. A multivariate regression was conducted to explore the moderating role of pain severity in the relationship between activity patterns and outcomes (i.e. fibromyalgia impact and depressive symptoms).

RESULTS

Excessive persistence (interaction: t = -2.45, p = 0.015) and pain-contingent persistence (interaction: t= -2.13, p = 0.034) were more strongly associated with fibromyalgia impact when people experienced less severe pain. Pacing for pain reduction was only significantly related to depressive symptoms at very severe (M = 10) pain levels (interaction: β= -0.18, t= -2.73).

CONCLUSIONS

The results here reported suggest that the context in which behaviour occurs is relevant when the utility of certain behaviour patterns is considered. The clinical implications of this are clear, as it would justify adapting the recommendations given to patients according to their pain severity status.

SIGNIFICANCE

This manuscript shows that some activity patterns (i.e. pacing to conserve energy for valued activities) might be advisable regardless of pain levels. Conversely, some patterns might be especially recommended (i.e. pain-reduction pacing) or inadvisable (i.e. excessive and pain-contingent persistence) depending on pain levels (i.e. severe and mild pain, respectively).

Overactivity assessment in chronic pain: The development and psychometric evaluation of a multifaceted self-report assessment

Background

Overactivity in the context of chronic pain (i.e. activity engagement that significantly exacerbates pain) is an important clinical issue that has gained empirical attention in the last decade. Current assessment concepts of overactivity tend to focus on frequency to quantify the severity of the pain behaviour. This study aimed to develop and validate a more comprehensive self‐assessment, the Overactivity in Persistent Pain Assessment (OPPA).

Methods

A sample of 333 individuals with chronic pain completed the OPPA. A subset of 202 individuals also completed a set of existing measures of pain‐related outcomes and activity patterns. The remaining 131 participants were provided with a second copy of the OPPA to fill in one week following their initial assessment.

Results

A principal component analysis confirmed that the OPPA items were best represented by a single construct. The OPPA was found to correlate with pain‐related measures in an expected way that is supported by both theory and qualitative data. When compared to existing overactivity measures, the OPPA was the only measure to contribute significantly to the regression models predicting higher levels of pain severity, more pain interference and lower levels of activity participation after controlling for age, gender and activity avoidance. In addition, the OPPA scale exhibited acceptable internal consistency and good test–retest reliability.

Conclusion

The results of this study reinforce the potentially important role of overactivity in the maintenance of pain‐related suffering and supports a corresponding assessment tool with preliminary psychometric evidence for clinical and research applications.

Significance

This study deconstructs the overactivity concept and develop a corresponding assessment based on five quantifiable severity features: severity of pain exacerbation, maladaptive coping strategies used, impact on occupational performance, recovery time and frequency. Results of the psychometric evaluation indicate that this comprehensive assessment of overactivity severity features may be necessary to understand the impact of overactivity on pain severity and physical functioning from both a clinical and research perspective.

The self-assessment INTERMED predicts healthcare and social costs of orthopaedic trauma patients with persistent impairments

Objective:

To use the self-assessment INTERMED questionnaire to determine the relationship between biopsychosocial complexity and healthcare and social costs of patients after orthopaedic trauma.

Design:

Secondary prospective analysis based on the validation study cohort of the self-assessment INTERMED questionnaire.

Setting:

Inpatients orthopaedic rehabilitation with vocational aspects.

Subjects:

In total, 136 patients with chronic pain and impairments were included in this study: mean (SD) age, 42.6 (10.7) years; 116 men, with moderate pain intensity (51/100); suffering from upper (n = 55), lower-limb (n = 51) or spine (n = 30) pain after orthopaedic trauma; with minor or moderate injury severity (severe injury for 25).

Main measures:

Biopsychosocial complexity, assessed with the self-assessment INTERMED questionnaire, and other confounding variables collected prospectively during rehabilitation. Outcome measures (healthcare costs, loss of wage costs and time for fitness-to-work) were collected through insurance files after case settlements. Linear multiple regression models adjusted for age, gender, pain, trauma severity, education and employment contract were performed to measure the influence of biopsychosocial complexity on the three outcome variables.

Results:

High-cost patients were older (+3.6 years) and more anxious (9.0 vs 7.3 points at HADS-A), came later to rehabilitation (+105 days), and showed higher biopsychosocial complexity (+3.2 points). After adjustment, biopsychosocial complexity was significantly associated with healthcare (ß = 0.02; P = 0.003; exp^ß = 1.02) and social costs (ß = 0.03; P = 0.006, exp^ß = 1.03) and duration before fitness-to-work (ß = 0.04; P < 0.001, exp^ß = 1.04).

Conclusion:

Biopsychosocial complexity assessed with the self-assessment INTERMED questionnaire is associated with higher healthcare and social costs.

Task-Contingent Persistence is Related to Better Performance-Based Measures in Patients with Chronic Musculoskeletal Pain

Purpose

Pacing, avoidance, and overdoing are considered the three main behavioral strategies, also labeled activity patterns. Their relationship with functioning of patients with chronic pain is debated. The purpose of this study was to measure the influence of activity patterns on lifting tasks commonly used in daily life.

Method

We performed a monocentric observational study and included patients performing Functional Capacity Evaluation (FCE). Avoidance, pacing, and persistence were assessed with using the Patterns of Activity Measures-Pain (POAM-P). Maximal safe performance was measured for floor-to-waist, waist-to-overhead, horizontal lift, and carrying with dominant-hand tests according to the FCE guidelines. Descriptive statistics, associations of POAM-P subscales with various sociodemographic variables, and correlations are presented. Standard multiple linear regression models were applied to measure the associations between FCE tests and POAM-P subscales, adjusting for the following potential confounders: age, gender, body mass index (BMI), pain severity, trauma severity, localization of injury, and education.

Results

Persistence was significantly positively associated with performance on the 4 FCE tests: floor-to-waist (coefficient = 0.20; p=0.001), waist-to-overhead (coefficient = 0.13; p=0.004), horizontal lift (coefficient = 0.31; p ≤ 0.001), and dominant-handed lifting (coefficient = 0.19; p=0.001). Pacing was found to have a negative influence on the carrying dominant-hand test (coefficient = -0.14; p=0.034), and avoidance was not found to have an influence on the 4 FCE tests.

Conclusion

This study shows that task-persistence pattern is positively associated with physical performance in FCE, whereas pacing can have a negative influence on some tests.

[Implementation of a new referral model for the musculoskeletal care pathway: Does it improve healthcare outcomes?]

OBJECTIVE

To evaluate the impact of an organisational change in the musculoskeletal referral pathway in our health management area (HMA) by identifying changes in the ability to improve healthcare outcomes by facilitating referral to the most suitable specialty.

DESIGN

This prospective descriptive study aimed to evaluate referral trends from primary care services (PCS) and hospital care (PHS) to musculoskeletal services from 2012 to 2018.

MATERIALS AND METHODS

We included all patients who were referred to any of the 3 musculoskeletal services from our HMA catchment area, without specifying sample size. The variables studied were PCS, PHS, service of origin and destination. We used the SPSS programme for the statistical analysis and obtained absolute frequency data.

RESULTS

The total number of referrals from PCS increased from 25,575 in 2012 to 24,871 in 2018. PHS referrals decreased from 17,207 in 2012 to 9,803 in 2018. With regards to PCS referrals, the service most increasing the number of referrals to the musculoskeletal team was the Rehabilitation Service, from 8.2% in 2012 to 47% in 2018. Regarding PHSs referrals by specialty, the service that most reduced the number of referrals to the musculoskeletal team was the Traumatology Service, from 10,587 in 2012 to 3,911 in 2018.

CONCLUSIONS

The redesign of the musculoskeletal referral pathway improved healthcare outcomes by improving the quality of the referral process. In this organisational change, the Rehabilitation Service took the leadership from the point of view of healthcare and management of the musculoskeletal process, collaborating in the improvement of the healthcare outcomes of these processes.