Development and Validation of the Athlete Fear Avoidance Questionnaire

Context

The fear-avoidance model was developed in an attempt to explain the process by which “pain experience” and “pain behavior” become dissociated from the actual pain sensation in individuals who manifest the phenomenon of exaggerated pain perception. High levels of fear avoidance can lead to chronic pain and disability and have successfully predicted rehabilitation time in the work-related–injury population. Existing fear-avoidance questionnaires have all been developed for the general population, but these questionnaires may not be specific enough to fully assess fear avoidance in an athletic population that copes with pain differently than the general population.

Objective

To develop and validate the Athlete Fear Avoidance Questionnaire (AFAQ).

Design

Qualitative research to develop the AFAQ and a cross-sectional study to validate the scale.

Patients or Other Participants

For questionnaire development, a total of 8 experts in the fields of athletic therapy, sport psychology, and fear avoidance were called upon to generate and rate items for the AFAQ. For determining concurrent validity, 99 varsity athletes from various sports participated.

Data Collection and Analysis

A total of 99 varsity athletes completed the AFAQ, the Fear-Avoidance Beliefs Questionnaire, and the Pain Catastrophizing Scale. We used Pearson correlations to establish concurrent validity.

Results

Concurrent validity was established with significant correlations between the AFAQ and the Fear Avoidance Beliefs Questionnaire-Physical Activity (r = 0.352, P > .001) as well as with the Pain Catastrophizing Scale (r = 0.587, P > .001). High internal consistency of our questionnaire was established with a Cronbach α coefficient of 0.805. The final version of the questionnaire includes 10 items with good internal validity (P < .05).

Conclusions

We developed a questionnaire with good internal and external validity. The AFAQ is a scale that measures sport-injury–related fear avoidance in athletes and could be used to identify potential psychological barriers to rehabilitation.Key Words: fear-avoidance model, scale, sports, athletic injuries, rehabilitation, psychology

Key Points

• We developed and validated the Athlete Fear Avoidance Questionnaire to assess pain-related fear in athletes.
• Pain-related fear or fear avoidance plays a critical role in the rehabilitation of patients with low back pain and work-related injuries. High levels of fear avoidance in athletes may affect rehabilitation times.

Most health professionals who work with injured athletes have encountered situations in which an athlete was struggling psychologically to return to play or the duration of rehabilitation was disproportionate to the athlete''s initial physical dysfunction. To date, a few scales measure athletes'' readiness to return to play, such as the Sports Inventory for Pain and the Injury–Psychological Readiness to Return to Sport Scale.^1,2 The Sports Inventory for Pain was developed specifically to identify beneficial and detrimental pain-coping strategies among the athletic population, but the authors worked with a student population to generate the items on the questionnaire, rather than a panel of experts in the field, and they did not establish concurrent validity. The Injury–Psychological Readiness to Return to Sport Scale was developed as a tool to assess an athlete''s confidence and psychological readiness to go back to play; however, it was designed to be administered at the end of an athlete''s rehabilitation process and, therefore, cannot be used to address psychological barriers at the beginning of rehabilitation that may lengthen the time to return to play.² Neither scale has been used extensively, but the fear-avoidance model (FAM), a psychological model well established in the general population, has been used extensively for its predictive value. For example, Sullivan et al³ noted that the Pain Catastrophizing Scale (PCS) has been cited more than 900 times on Web of Science since 1995.The FAM is based on the emotional reaction of pain perception and high levels of fear avoidance that can lead to dysfunction.⁴ The FAM was created in an attempt to explain the development of chronic pain from acute pain. The model comprises 4 components: fear of pain, kinesiophobia, fear-avoidance belief, and catastrophizing. According to the FAM, exaggerated pain perception could lead to the development of chronic pain,⁴ and fear of pain is a main focus. There are 2 possible coping reactions to fear of pain: confrontation and avoidance. Individuals who experience elevated levels of fear of pain with signs of fear avoidance in response to acute pain are more likely to develop chronic pain than those who confront their fear of pain.⁴ The FAM assessment tools were all developed for the general population or patients with chronic low back pain. The main questionnaires used to assess the 4 components of the FAM are the Fear of Pain Questionnaire-III, the PCS, the Tampa Scale for Kinesophobia, and the Fear-Avoidance Beliefs Questionnaire (FABQ). The FABQ was developed in part for patients with work-related injuries.⁵ Injured varsity athletes may not relate to work-specific items on the FABQ, such as “My pain was caused by my work or by an accident at work.” Although some of the questionnaires, such as the PCS, have been validated on athletes, they were not developed specifically for the athletic population.⁶ In fact, the FAM questionnaires can be used to predict outcomes.^7,8 Klenerman et al⁷ conducted a study to determine whether chronic pain could be predicted from acute low back pain in the general population. Results indicated that patients with acute low back pain either will improve within 2 months or will develop chronic pain and that the FAM appears to be the best predictor of the course of low back pain within the first 2 months.⁷ In another study, Fritz and George⁸ aimed to identify psychosocial factors that could predict return to work in patients with acute work-related back pain. The results revealed that the FABQ-Work (FABQ-W) was the strongest predictor of work status and may be used to predict return to work in patients with acute work-related low back pain.⁸ The authors of the PCS also established that people who catastrophize have higher levels of pain and disability than people who do not.⁹Some studies have indicated that parts of the FAM can influence athletes'' rehabilitation.^6,10,11 Kvist et al¹⁰ also reported on the psychological effect an injury can have on a player. Of the 47% who did not return to their sport, 24% did not return to play because of their fear of reinjury.¹⁰ People who returned to their preinjury levels of activity had the lowest levels of fear of reinjury, whereas people who did not return to their preinjury levels of activity had a higher fear of reinjury.¹⁰ The results of these studies might have been stronger using a scale that was developed specifically for athletes. To date, no questionnaire or scale has been specifically developed to assess fear avoidance or pain-related fear in athletes, who differ from the general population in their mentality and reality (ie, the role of sports or activity in their lives). Furthermore, athletes are exposed to pain and sports injuries relatively often, so knowing whether fear avoidance is a major concern among that population is important. Therefore, taking fear avoidance into account might be useful to establish the most appropriate and effective rehabilitation plan and, consequently, to reduce the time for return to play. A questionnaire specific to athletes might help establish how the FAM or pain-related fear can influence the athletic population, specifically regarding rehabilitation.Therefore, the aims of our study were to develop and validate the Athlete Fear Avoidance Questionnaire (AFAQ). We used a qualitative study design, a modified Delphi technique, to develop the scale and then a cross-sectional study to establish its validity.     

Influence of hydroxyurea on fetal hemoglobin production in vitro

Cytotoxic drugs increase circulating fetal hemoglobin levels. We examined the mechanism by measuring the fetal hemoglobin produced per BFU-E-derived erythroblast following hydroxyurea treatment in vivo and in vitro. Treatment of four sickle cell patients increased the percentage of circulating F reticulocytes. The frequencies of bone marrow or peripheral blood BFU-E or CFU-E-derived colonies and their fetal hemoglobin content were unaffected. In all cases, the number of erythroid cells/progenitor-derived colony increased. To explore further the effect of hydroxyurea on fetal hemoglobin production, we added 50 mumol/L hydroxyurea to cultures of peripheral blood BFU-E-derived erythroblasts on 1 of 9 days (day 5 through 13) to nine samples. These BFU-E were derived from the peripheral blood of normal donors, sickle trait donors, and sickle cell anemia patients and from the bone marrows of monkeys. This concentration of hydroxyurea was selected so that the frequency of BFU-E and their size was moderately decreased. Addition of hydroxyurea to these progenitor-derived erythroid cells had no effect on fetal hemoglobin content per cell. Neither did transient exposure of progenitors to hydroxyurea prior to culture in nontoxic concentrations (0 to 500 mumol/L) result in a significant increase in fetal hemoglobin content in progenitor-derived erythroblasts. These data suggest that hydroxyurea does not directly alter the HbF program expressed by progenitor-derived erythroid cells. Instead, it enhances hemoglobin F content secondarily, possibly by inducing alterations in erythropoiesis.     

Hydroxyurea: effects on hemoglobin F production in patients with sickle cell anemia.

Patients with sickle cell anemia were treated with daily doses of hydroxyurea, to assess pharmacokinetics, toxicity, and increase in fetal hemoglobin (Hb) production in response to the drug. Plasma hydroxyurea clearances were not a useful guide to maximum tolerated doses of the drug. The mean daily single oral dose that could be maintained for at least 16 weeks was 21 mg/kg (range, 10 to 35 mg/kg). Among 32 patients, last HbF levels were 1.9% to 26.3% (mean, 14.9%) with increases in HbF over initial values of 1.4% to 20.2% (mean, 11.2%). The most significant predictors of last HbF were last plasma hydroxyurea level, initial white blood count and initial HbF concentration. Last HbF was not related to beta globin haplotype or alpha globin gene number. No serious toxicity was encountered. Clinically significant bone marrow depression was avoided, and chromosome abnormalities after 2 years of treatment were no greater than those observed before treatment. The period of observation has been too short to evaluate the risk of carcinogenesis. Patient's red cells developed striking macrocytosis. Median red cell Hb concentrations did not change. Hb concentrations increased, on average 1.2 g/dL, but serum erythropoietin levels increased. Patients' body weights increased, and some returned to work or school, but no conclusions regarding therapeutic efficacy could be drawn from this uncontrolled open-label study.     

Characterization of 9 polymorphic microsatellite loci in Lamellibrachia sp. 2, a tubeworm found at deep-sea hydrothermal vents and cold seeps

Lamellibrachia sp. 2 is a deep-sea vestimentiferan tubeworm found at hydrothermal vents on the Mid-Cayman Spreading Center and at hydrocarbon seeps in the Gulf of Mexico and off the coast of Barbados. Nine selectively neutral and unlinked polymorphic microsatellite loci were developed for this species. Eight of these loci conformed to Hardy–Weinberg expectations. Average observed heterozygosity ranged from 0.14 to 0.92. Microsatellites developed for Lamellibrachia sp. 2 are being deployed to study connectivity and gene flow among populations of this species.     

Hydroxyurea-induced augmentation of fetal hemoglobin production in patients with sickle cell anemia

Five patients with sickle cell anemia were treated with hydroxyurea (HU), in hopes of augmenting their production of fetal hemoglobin. Laboratory responses in two patients treated for more than 2 years were encouraging and there were suggestions of clinical improvement. Long- term HU therapy should be considered for severely affected adults with sickle cell anemia who are willing to accept what is probably a small risk of carcinogenesis. Preliminary chromosomal analysis and knowledge of the clastogenic properties of HU suggest that conception and pregnancy should be avoided. Pharmacokinetic studies will probably be necessary to adjust individual dosage schedules so that cytotoxicity is avoided. F cell responses can be seen in 2 to 3 weeks if the HU dose is optimal, but establishment of a large number of F cells in the circulation may take a month or longer.     

HbA1c Is Disproportionately Higher in Women and Older People With Type 1 Diabetes Compared With Flash Glucose Monitoring Metrics of Glycemic Control

Aims:Discrepancy between HbA1c and glucose exposure may have significant clinical implications. We sought to assess predictors of disparity between HbA1c and flash monitoring metrics and how these relate to microvascular complications.Methods:We conducted a cross-sectional study of adults with type 1 diabetes (n = 518). We assessed the relationship between clinic HbA1c and flash monitoring metrics, predictors of discrepancy between these measurements, and whether discrepancy was associated with microvascular complications.Results:Actual HbA1c and estimated HbA1c were strongly correlated (r = .779, P < .001). The likelihood of having a higher actual HbA1c than estimated HbA1c was greater with increasing age (OR = 1.055 per year, P < .001) and lower in men (OR = .208, P < .001). HbA1c was significantly lower in men (58 mmol/mol [51-67]) (7.5% [6.8-8.3]) compared to women (61 mmol/mol [54-70], P = .021) (7.7% [7.1-8.6]), despite no significant differences in any flash monitoring metrics. Whereas HbA1c was not different between younger (≤39 years) and older individuals (>39 years) despite significantly higher glucose exposure, in younger people, based on multiple flash monitoring metrics. Having a lower estimated than actual HbA1c was independently associated with a lower prevalence of retinopathy (OR = .55, P = .004).Conclusions:HbA1c appears to overestimate glucose exposure in women and older people with type 1 diabetes. This has potentially important clinical implications, as is hinted at by the independent relationship with retinopathy prevalence. It may also be of relevance when considering the use of HbA1c for the diagnosis of diabetes.