Pain-related fear at the start of a new low back pain episode

Previous research supports the fear-avoidance model in explaining chronic low back pain (LBP) disability. The aims of the present study were to determine: (1) whether fear-avoidance model variables are associated already during acute stages of LBP and (2) whether (increases in) pain-related fear are associated with other patient characteristics routinely assessed by the General Practitioner (GP). General practice patients consulting because of a new episode of LBP completed questionnaires on pain-related fear, avoidance, pain and disability. A sample of 247 acute LBP patients (median duration of current episode was 5 days) was collected. Significant associations were found between pain intensity, pain-related fear, avoidance behaviour and disability, but correlations were generally modest. A strong association was found between pain and disability. Pain-related fear was slightly higher in patients reporting low job satisfaction and in those taking bedrest. These results suggest that the fear-avoidance model as it was developed and tested in chronic LBP, might not entirely apply to acute LBP patients. Future research should focus on the transition from acute to chronic LBP and the shifts that take place between fear-avoidance model associations.     

A longitudinal study on the predictive validity of the fear-avoidance model in low back pain

Recently, fear-avoidance models have been quite influential in understanding the transition from acute to chronic low back pain (LBP). Not only has pain-related fear been found to be associated with disability and increased pain severity, but also treatment focused at reducing pain-related fear has shown to successfully reduce disability levels. In spite of these developments, there is still a lack in well-designed prospective studies examining the role of pain-related fear in acute back pain. The aim of the current study was to prospectively test the assumption that pain-related fear in acute stages successfully predicts future disability. Subjects were primary care acute LBP patients consulting because of a new episode of LBP (相似文献   

Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability

There is growing evidence for the idea that in back pain patients, pain-related fear (fear of pain/physical activity/(re)injury) may be more disabling than pain itself. A number of questionnaires have been developed to quantify pain-related fears, including the Fear-Avoidance Beliefs Questionnaire (FABQ), the Tampa Scale for Kinesiophobia (TSK), and the Pain Anxiety Symptoms Scale (PASS). A total of 104 patients, presenting to a rehabilitation center or a comprehensive pain clinic with chronic low back pain were studied in three independent studies aimed at (1) replicating that pain-related fear is more disabling than pain itself (2) investigating the association between pain-related fear and poor behavioral performance and (3) investigating whether pain-related fear measures are better predictors of disability and behavioral performance than measures of general negative affect or general negative pain beliefs (e.g. pain catastrophizing). All three studies showed similar results. Highest correlations were found among the pain-related fear measures and measures of self-reported disability and behavioral performance. Even when controlling for sociodemographics, multiple regression analyses revealed that the subscales of the FABQ and the TSK were superior in predicting self-reported disability and poor behavioral performance. The PASS appeared more strongly associated with pain catastrophizing and negative affect, and was less predictive of pain disability and behavioral performance. Implications for chronic back pain assessment, prevention and treatment are discussed.     

Fear of movement/(re)injury, disability and participation in acute low back pain

Fear of movement/(re)injury and its associated avoidance behavior have shown to be strongly associated with functional disability in chronic low back pain. In acute low back pain disability, the role of pain-related fear has received little research attention so far. Measures of pain-related fear such as the Tampa Scale for Kinesiophobia (TSK) are increasingly being used in primary care. The aim of the present study was: (1). to further investigate the factor structure of the TSK in a population of acute low back pain (LBP) patients in primary care by means of a confirmatory factor analysis (CFA); (2). to examine the relationship between fear of movement/(re)injury and disability, as well as participation in daily and social life activities in 615 acute LBP patients seen by general practitioners and physical therapists in primary care settings; and (3). to examine whether disability mediates the association between pain-related fear and participation. CFA, and a subsequent explorative factor analysis on the TSK revealed a two-factor model. The factors consisted of items associated with 'harm', and items representing the 'avoidance of activity'. Both constructs were significantly associated with disability and participation. Additionally, and in contrast to what is often observed in chronic pain, disability, and to a lesser degree participation, were also associated with pain intensity. Finally, the association between pain-related fear, pain intensity and participation was indeed mediated by disability. The results suggest that early on in the development of LBP disability, the successful reduction of pain-related fear and disability might foster increased participation in daily and social life activities.     

Pain-related fear in acute low back pain: the first two weeks of a new episode.

The overall aim of this study was to explore the natural course of pain-related fear during the early stage of a new low back pain episode, using a prospective case series design. Specific research questions addressed the existence of typical patterns in individual time series of pain-related fear and sequential relationships between the occurrence of pain-related fear, pain and pain catastrophizing. Forty-four general practice patients who consulted their physician with a new episode of non-specific low back pain were recruited. They completed diaries on pain-related fear, pain and pain catastrophizing for 14 days following the consultation. Follow-up questionnaires on disability were completed at 3 months and 12 months. Time series analyses produced subgroups of patients with descending, stable and rising levels of pain-related fear over the 2-week period. These groups differed on baseline characteristics and outcome at follow-up. A time-shift between the occurrence of pain-events and pain-related fear or pain catastrophizing could not be demonstrated.In summary, these results fit in with previous findings in chronic patients. A relevant subgroup of patients who might benefit from early intervention could be identified. These findings support the need for further research into fear mechanisms in acute low back pain.     

Reduction of pain-related fear and increased function and participation in work-related upper extremity pain (WRUEP): Effects of exposure in vivo

There is increasing evidence that pain-related fear influences the development and maintenance of pain disability, presumably mediated through the fear-related avoidance of valued activities. Individually tailored graded exposure in vivo (GEXP) has been demonstrated to reduce pain-related fear and increase functional abilities in patients with chronic low back pain, neck pain, and complex regional pain syndrome. The current study aimed to test whether these effects generalize towards patients with work-related upper extremity pain. A sequential replicated and randomized single-case experimental phase design with multiple measurements was used. Within each participant, GEXP was compared to a no-treatment baseline period and a no-treatment 6-month follow-up period. Eight patients who reported a high level of pain-related fear were included in the study. Daily changes in pain catastrophizing, pain-related fear, and pain intensity were assessed using a diary, and subjected to randomization tests. Before the start of the baseline period, just after GEXP, and at 6-month follow-up, clinically relevant changes of pain catastrophizing, pain-related fear, perceived harmfulness of physical activity, pain disability, and participation/autonomy were verified. When GEXP was introduced, levels of pain catastrophizing and pain-related fear decreased significantly. Clinically relevant improvements were observed for pain disability, perceived participation, and autonomy. These favourable changes were maintained until 6-month follow-up. The findings of the current study underscore the external validity of a cognitive-behavioural GEXP treatment for patients with chronic pain reporting increased pain-related fear.     

Predicting pain and disability in patients with hand fractures: Comparing pain anxiety,anxiety sensitivity and pain catastrophizing

There is a range of anxiety-related constructs associated with pain and pain-related disability. Those most often examined are pain catastrophizing, pain anxiety and anxiety sensitivity. All three are conceptualized to be important in the development and maintenance of chronic pain, and are included within fear avoidance models. Surprisingly these constructs are not routinely examined together, and when they are, have been investigated in healthy individuals using experimental techniques or patients with chronic conditions. Although these constructs are also thought to be important in acute clinical pain, they tend not to been examined together in the same study. The focus of the current research was therefore to examine these three anxiety-related constructs in an acute pain setting, and examine their relative influence on both pain and pain-related functional disability. Participants were 82 patients with a hand fracture, recruited from a fracture clinic at a general hospital. They completed a battery of measures related to anxiety, pain and disability. Once controlling for injury-related variables, catastrophizing was found to predict current pain, pain-related anxiety predicted task-related pain, whereas anxiety sensitivity was (negatively) associated with disability. These findings are discussed in light of the relative role that these anxiety-related constructs have in pain and disability, as well as implications for future research.     

Low levels of physical activity in back pain patients are associated with high levels of fear‐avoidance beliefs and pain catastrophizing

Background and Purpose. Fear‐avoidance beliefs are important determinants for disability in patients with non‐specific low‐back pain (LBP). The association with self‐reported level of physical activity is less known. The aim of the present study was to describe the level of physical activity in patients with chronic non‐specific LBP and its relation to fear‐avoidance beliefs and pain catastrophizing. Method. A cross‐sectional study on 64 patients with chronic non‐specific LBP in primary healthcare. The variables measured and the questionnaires used were: level of physical activity (six‐graded scale); activity limitations (Roland Morris Disability Questionnare (RDQ)); fear‐avoidance beliefs (Tampa Scale of Kinesiophobia (TSK) 13‐item and sub‐scales ‘activity avoidance’ and ‘somatic focus’); and pain catastrophizing (Pain Catastrophizing Scale (PCS)). The level of physical activity was dichotomised into low and high physical activity. Individual median scores on the TSK and PCS scales were used to group the patients into different levels of fear‐avoidance beliefs and pain catastrophizing. Univariate logistic regressions were used to calculate odds ratios for having low physical activity. Results. Patients with low physical activity had significantly higher scores in fear‐avoidance beliefs and pain catastrophizing (p < 0.05). Odds ratios for low level of physical activity were between 4 and 8 (p < 0.05) for patients with high fear‐avoidance beliefs or medium/high pain catastrophizing. Conclusions. This study indicates that it seems important for physiotherapists in primary care to measure levels of fear‐avoidance beliefs or pain catastrophizing. In particular, the two subscales of the TSK could be of real value for clinicians when making treatment decisions concerning physical exercise therapy for patients with chronic LBP. Copyright © 2007 John Wiley & Sons, Ltd.     

Distraction from chronic pain during a pain-inducing activity is associated with greater post-activity pain

The aim of this study was to investigate the effects of distraction from pain during and after a pain-inducing lifting task in a sample of chronic low back pain (CLBP) patients. Fifty-two CLBP patients (25 males, 27 females; mean age=46.30 years) performed a pain-inducing lifting task twice, once alone and once with a simultaneous cognitive distraction task. The results revealed that (1) distraction had no effect upon self-reported pain during the lifting task, (2) distraction had a paradoxical effect of more pain immediately after the lifting task, (3) both pain-related fear and pain catastrophizing did not moderate the effects of distraction on pain, but (4) catastrophic thinking about pain during the lifting task was related to more vigilance to pain and less engagement in the distracting task. Further investigation of the catastrophizing data showed that the effect of catastrophizing about pain during the lifting task on the cognitive distraction task was mediated by the amount of attention paid to pain. Clinical implications of these findings are discussed.     

Catastrophizing is associated with pain intensity,psychological distress,and pain-related disability among individuals with chronic pain after spinal cord injury

Little research has examined the role of patient cognitive and behavioral responses, including catastrophizing, in adjustment to chronic pain associated with spinal cord injury (SCI). The objective of this study was to examine the associations of catastrophizing and specific pain coping strategies with pain intensity, psychological distress, and pain-related disability among individuals with chronic pain and SCI, after controlling for important demographic and SCI-related variables that might affect outcomes. Participants in this study were 174 community residents with SCI and chronic pain who completed a mailed questionnaire that included the SF-36 Mental Health scale, Coping Strategies Questionnaire, and Graded Chronic Pain Scale. The pain coping and catastrophizing measures explained an additional 29% of the variance in pain intensity after adjusting for the demographic and SCI variables (P<0.001). The coping and catastrophizing scales accounted for an additional 30% of the variance in psychological distress (P<0.001) and 11% of the variance in pain-related disability (P<0.001), after controlling for pain intensity and demographic and SCI variables. Catastrophizing, but not any other single pain coping strategy, was consistently strongly and independently associated with the outcome measures. Potentially, the assessment and treatment of catastrophizing may reduce psychological distress and pain-related disability among individuals with chronic pain and SCI.     

Differential predictors of the long-term levels of pain intensity, work disability, healthcare use, and medication use in a sample of workers' compensation claimants

The fear avoidance model of pain (FAM) conceptualizes pain catastrophizing as the cognitive antecedent of pain-related fear, and pain-related fear as the emotional antecedent of depression and disability. The FAM is essentially one of mediation whereby pain-related fear becomes the process by which depression or disability ensue. However, emerging literature suggests that pain catastrophizing, pain-related fear, and depression might be at least partially distinct in their prediction of different pain-related outcomes. The primary purpose of the present study was to evaluate whether psychological factors in the FAM (pain catastrophizing, pain-related fear, and depression) differentially predict long-term pain-related outcomes. Toward this objective, we conducted a prospective study using a cohort of 202 individuals with subacute work-related musculoskeletal injuries. Participants completed a 7-week physical therapy program with a functional rehabilitation orientation. Posttreatment measures of fear of movement, pain catastrophizing, depression, and pain self-efficacy were used to predict the persistence of pain symptoms, healthcare use, medication use, and return-to-work at one-year follow-up. Results from hierarchical linear and logistic regression analyses revealed that pain catastrophizing and fear of movement act as differential predictors of long-term pain-related outcomes. Specifically, we found unique relationships between pain catastrophizing and long-term pain intensity, and fear of movement and long-term work disability. After controlling for pain intensity and FAM variables, pain self-efficacy was shown to be a unique predictor of medication use. Implications for the FAM and the clinical management of musculoskeletal pain conditions are discussed.     

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

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

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

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

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

BACKGROUND AND OBJECTIVE: Several cognitive-behavioral factors contribute to the persistence of pain disability in patients with chronic back pain. Fear-avoidance beliefs and fear of movement/(re)injury in particular have been shown to be strong predictors of physical performance and pain disability. Patients reporting substantial pain-related fear might benefit from exposure in vivo to a set of individually tailored, fear-eliciting, and hierarchically ordered physical movements rather than more general graded activity. PATIENTS AND INTERVENTIONS: Six consecutive patients with chronic low back pain who reported substantial fear of movement/(re)injury were included in the study. After a no-treatment baseline measurement period, the patients were randomly assigned to one of two interventions. In the first intervention, patients received exposure in vivo first, followed by graded activity. In the second intervention, the sequence of treatment modules was reversed. Before each treatment module, treatment credibility was assessed. Daily measures of pain-related fear, pain catastrophizing, and pain intensity were completed using visual analog scales. In addition, standardized measures of pain disability, pain-related fear, and pain vigilance were taken before and after each treatment module and at the 1-year follow-up. To obtain more objective data on actual activity levels, an ambulatory activity monitor was carried by the patients during 1 week before and after each treatment module. RESULTS: Time series analysis of the daily measures showed that improvements in pain-related fear and pain catastrophizing occurred only during the exposure in vivo and not during the graded activity, irrespective of the treatment order. Analysis of the pretreatment to post-treatment differences also revealed that decreases in pain-related fear also concurred with decreases in pain disability and pain vigilance and an increase in physical activity levels. All improvements remained at the 1-year follow-up.     

Attentional Biases Toward Sensory Pain Words in Acute and Chronic Pain Patients

Attentional biases towards pain-related words of chronic and acute low back pain (LBP) patients were compared with healthy pain-free controls. Specifically, the aims were to determine: 1) whether chronic LBP patients demonstrate attentional biases compared to pain-free controls; 2) whether observed biases are also present in those with acute LBP; and 3) whether observed biases are associated with pain-related fear among the pain groups. Four groups were recruited: 1) acute LBP patients; 2) chronic LBP patients from physiotherapy practices; 3) chronic LBP patients from a tertiary referral pain-management center; and 4) healthy pain-free controls. Participants were assessed on the dot-probe computer task for attentional bias to pain-related words. All 3 pain groups demonstrated biases compared to controls on sensory but not on affective, disability, or threat words. Among the pain groups, those with low and moderate levels of fear of (re)injury demonstrated biases towards sensory pain words that were absent in those with high levels of fear, which is counterintuitive to what the fear of (re)injury model suggests. These results suggest that the experience of pain, rather than duration, is the primary indicator of the presence of pain-related biases.     

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

AIM OF INVESTIGATION: To evaluate whether a perceived decline in the level of physical activity after the onset of pain (PAD) is more appropriate in the explanation of disability as compared to the actual level of physical activity (PAL) in patients with sub-acute back pain. METHODS: Patients with 4-7 weeks of non-specific low back pain (LBP) participated in this study. Their habitual physical activity level before the back pain started (H-PAL), their actual level of physical activity (PAL) and their perceived decline in the level of physical activity after the onset of pain (PAD) were assessed. The association between these physical activity related variables and perceived disability (QBPDS), fear of movement/(re)injury (TSK), pain catastrophizing (PCS) and pain intensity (VAS) was examined. The role of PAD as a mediator in the association between fear of movement/(re)injury and disability was examined by three linear regression analyses. RESULTS: 123 patients (66 male and 57 female) with a mean age of 44.1 years (SD=10.3) participated in this study. PAD was significantly correlated with disability, fear of movement/(re)injury, pain catastrophizing and pain intensity. PAD and PAL appeared more important in the explanation of disability in the subgroup of patients who were physically active before their back pain started. Generally, PAD indeed mediated the association between fear of movement/(re)injury and disability. CONCLUSIONS: The perceived decline in physical activity, rather than the current physical activity itself is important in the evaluation of the impact of activity related changes on disability in low back pain.     

Pain-related catastrophizing and perceived social responses: Inter-relationships in the context of chronic pain

Pain-related coping, particularly catastrophizing, plays a significant role in shaping pain responses. One way catastrophizing is hypothesized to amplify pain and disability is via its effect on patients' social environments (e.g., communal coping model), though empirical support is limited. The present study tested whether the association between catastrophizing and deleterious pain-related outcomes was mediated by patients' perceptions of significant others' responses to their pain in a sample of 1356 pain patients. Regression analyses showed that perceived significant other punishing responses partially mediated catastrophizing's relationship with pain-related disability, and with depressive symptoms. Further, several variables moderated the association between catastrophizing and perceived social responses to pain. Catastrophizing was more strongly associated with greater perceived solicitous responses for patients of relatively short pain duration. Also, higher catastrophizing was more strongly associated with perceived punishing responses among patients perceiving lower social support. In addition, the mediational effects of perceived punishing responses on catastrophizing's relationship with depressive symptoms, and with pain-related disability were only found in individuals reporting low levels of perceived social support. In sum, perceived social responses were found to play a small role in mediating the relationship between catastrophizing and pain-related outcomes, and these mediational effects may be strongest in particular patient subgroups. The present data suggest that interpersonal mechanisms may not constitute a primary route by which catastrophizing exerts its maladaptive effects on pain responses. The study and further understanding of what principal factors mediate catastrophizing's deleterious effects on pain will be important in illuminating the biopsychosocial model of pain.     

Activity-related summation of pain and functional disability in patients with whiplash injuries

This study investigated the relation between repetition-induced summation of activity-related pain (RISP) and indicators of functional disability in a sample of 62 individuals who had sustained whiplash injuries. Participants completed measures of pain severity, pain catastrophizing, fear of movement and depression prior to lifting a series of 36 weighted canisters. An index of RISP was computed as the increase in pain reported by participants over successive lifts of the weighted canisters. Measures of functional disability included physical lifting tolerance, self-reported disability and perceived work demands. Regression analyses revealed that the index of RISP accounted for significant variance in measures of lifting tolerance and perceived work demands, even when controlling for age, sex and pain severity. The index of RISP was also significantly correlated with pain catastrophizing and pain duration. The discussion addresses the mechanisms by which physiological and psychological factors might contribute to increases in pain during repeated physical activity. Discussion also addresses whether RISP might represent a risk factor for problematic recovery outcomes following whiplash injury.     

The role of neuroticism, pain catastrophizing and pain-related fear in vigilance to pain: a structural equations approach

The present study aimed at clarifying the precise role of pain catastrophizing, pain-related fear and personality dimensions in vigilance to pain and pain severity by means of structural equation modelling. A questionnaire survey was conducted in 122 patients with chronic or recurrent low back pain. Results revealed that pain catastrophizing and pain-related fear mediated the relationship between neuroticism and vigilance to pain. Furthermore, vigilance to pain was found to be associated with heightened pain severity. Finally, we found that neuroticism moderated the relationship between pain severity and catastrophic thinking about pain. The results strongly support the idea that vigilance to pain is dependent upon catastrophic thinking and pain-related fear. Neuroticism is best conceived of as a vulnerability factor; it lowers the threshold at which pain is perceived as threatening, and at which catastrophic thoughts about pain emerge.     

Fear of movement/(re)injury in chronic pain: a psychometric assessment of the original English version of the Tampa scale for kinesiophobia (TSK)

The Tampa scale for kinesiophobia (TSK) was developed to measure fear of movement/(re)injury in chronic pain patients. Although studies of the Dutch adaptation of the TSK have identified fear of movement/(re)injury as an important predictor of chronic pain, pain-related avoidance behaviour, and disability, surprisingly little data on the psychometric properties of the original English version of the TSK are available. The present study examined the reliability, construct validity and factor structure of the TSK in a sample of chronic pain patients (n=200) presenting for an interdisciplinary functional restoration program. Consistent with prior evaluations of the Dutch version of the TSK, the present findings indicate that the English TSK possesses a high degree of internal consistency and is positively associated with related measures of fear-avoidance beliefs, pain catastrophizing, pain-related disability and general negative affect. The TSK was not related to individual differences in physical performance testing as assessed using standardised treadmill and lifting tasks. Confirmatory factor analyses suggest that the TSK is best characterized by a three-factor trait method model that includes all 17 of the original scale items and takes into account the distinction between positively and negatively keyed items. The results of the present study provide important details regarding the psychometric properties of the original English version of the TSK and suggest that it may be unnecessary to remove the negatively keyed items in an attempt to improve scale validity.