Abstract: Dyspnea-related anxiety may lead to reduced quality of life and functional disability through fearful avoidance of dyspnea-evoking activity. We describe the validation of a generic - diagnosis-independent - instrument assessing dyspnea-related anxiety. A total of 187 patients with respiratory diseases completed the Breathlessness Beliefs Questionnaire (BBQ), a 17-item questionnaire adapted from the Tampa Scale for Kinesiophobia (TSK), a measure of how harmful pain patients think painful movement is and to what extent they think activity should be avoided. Measures of negative and positive affectivity (PANAS), anxiety and depression (HADS), functional status (PFSDQ), and health-related quality of life (CRDQ) were also completed. Principal component analysis and item-total correlations suggested a reliable (reduced) 11-item BBQ (Cronbach's alpha = .85) with two factors converging with the TSK factors: a 'somatic focus' factor assessing the harmfulness of dyspnea and the underlying pathology and an 'activity avoidance' factor assessing beliefs that activity should be avoided. Correlational analyses support the construct validity of the BBQ: higher scores on the BBQ are associated with reduced health-related quality of life and functional status. Associations between 'somatic focus' and negative affectivity and anxiety and between 'activity avoidance' and positive affectivity and depression further supported the validity of the BBQ and its subscales. The BBQ is a valid, short, and useful instrument to assess respiratory patients' beliefs about the harmfulness of their disease and physical activities. Further research is needed to document to what extent BBQ scores are related to daily life activities and symptoms.
Abstract: Chronic pain not only interferes with daily activities, it may also have a negative impact on the perceived integrity of one's self through self-discrepancies. Self-discrepancies are experienced distances between the actual self and self-guides that can exist from 2 perspectives (ie, own and other). Self-discrepancies are associated with negative mood states and incite self-regulatory behavior in order to reduce these discrepancies. The present study was aimed at replicating the emotional consequences of self-discrepancies in patients with chronic low back pain, and extending current knowledge of the behavioral consequences of self-discrepancies (ie, behavioral activity patterns such as avoidance and persistence). A cross-sectional design was employed with 83 patients who completed a number of self-report measures. We hypothesized that ideal and ought discrepancies, as well as feared congruencies were associated with depressed and anxious mood. On the behavioral level, a U-shaped relationship was hypothesized between ideal and ought self-discrepancies and persistence behavior, whereas feared self-discrepancies were hypothesized to be related to avoidance behavior. Results were partially in line with the hypotheses. With respect to the emotional consequences, feared (own and other) self-discrepancies were predictive of depressive and anxious mood. With regard to activity patterns, results showed a U-shaped relationship between ideal-other self-discrepancies and persistence behavior and a positive relationship between feared-own self-discrepancies and avoidance behavior. In contrast to expectations, none of the other self-discrepancies was related to activity patterns. Of interest was that avoidance, but not persistence behavior, was predictive of higher levels of disability and lower levels of quality of life. Support is provided for the role of self-discrepancies in the emotional well-being and behavioural patterns of patients with chronic low back pain.
Abstract: Although direct experience and verbal instruction are important sources in the development of pain-related beliefs and behaviors, accumulating evidence indicates that observation of others in pain may be equally as important. Taking a contemporary view on learning as a starting point, we discuss available evidence on observational learning in the context of pain, highlight its importance for both development and management of chronic pain problems, and discuss potential moderators of observational learning effects. We argue that the capacity to understand and appreciate the experience of another person is fundamental to observational learning, including use of this information to establish the association between pain and antecedent or consequent stimuli. A main objective of this paper is to stimulate research on the role of learning about pain from others. Several lines for further research, including clinical applications, are delineated. PERSPECTIVE: Based upon a contemporary view on learning, this focus article delineates how pain-related beliefs and behaviors may be learnt by observing others. It is discussed how further research on the acquisition of pain-related beliefs/behaviors might further our understanding of pain and disability.
Abstract: This study examines the changes in self-perception during resolution of an acutely painful neck injury sustained in a motor vehicle accident. We tested predictions from self-discrepancy theory and a model of self-pain enmeshment. Measures of discrepancy between the current (actual) self and both the ideal and feared-for self were predicted to remain stable over a 21-day recovery period whereas a measure of enmeshment was predicted to decrease as pain resolved. We also examined the relationship between daily ratings of achievement in several domains and participants perceived ideal performance. Sixty patients with possible acute neck injury recruited within 1 month after a motor vehicle accident gave consent and data were obtained from 42 participants. Standard questionnaire measures of pain, disability, fear of movement, pain catastrophizing and self-discrepancies, self-pain enmeshment and data from diaries (measures of pain, mood, self-discrepancies, pain catastrophizing and fear of movement) were obtained. In general the relationships between the measures of self-discrepancy and enmeshment and mood were in accord with both theoretical predictions and previous observations. Resolution of pain was associated with a reduction in enmeshment but not to change in self-discrepancy. Multilevel analyses of the diary data showed that concordance between actual and ideal performance increased over the 21 days of data collection. These data provide preliminary support for aspects of self-discrepancy theory and the self-pain enmeshment model.
Abstract: The present study aimed to develop norms for the Tampa Scale for Kinesiophobia (TSK), a frequently used measure of fear of movement/(re)injury. Norms were assessed for the TSK total score as well as for scores on the previously proposed TSK activity avoidance and TSK somatic focus scales. Data from Dutch, Canadian, and Swedish pain samples were used (N=3082). Norms were established using multiple regression to obtain more valid and reliable norms than can be obtained by subgroup analyses based on age or gender. In the Dutch samples (N=2236), pain diagnosis was predictive of all TSK scales. More specifically, chronic low back pain displayed the highest scores on the TSK scores followed by upper extremity disorder, fibromyalgia, and osteoarthritis. Gender was predictive of TSK somatic focus scores and age of TSK activity avoidance scores, with male patients having somewhat higher scores than female patients and older patients having higher scores compared with younger patients. In the Canadian (N=510) and Swedish (N=336) samples, gender was predictive of all TSK scales, with male patients having somewhat higher scores than female patients. These norm data may assist the clinician and researcher in the process of decision making and treatment evaluation. Norms scores of the Tampa Scale for Kinesiophobia were established using data from Dutch, Canadian, and Swedish pain samples (N=3082).
Abstract: OBJECTIVES:: Expressing the outcomes of treatment in quality-adjusted life years is increasingly important as a tool to aid decision makers concerning the allocation of scarce resources within the health care sector. A quality-adjusted life year is a measure of life expectancy that is weighted by health-related quality of life. These weights are referred to as utility scores and are usually measured by multiattribute utility measures. Several studies found that different utility measures provide different estimates of the same person's level of utility. The aim of this study was to investigate which of two widely used utility measures, the EQ-5D and the HUI mark III, is preferred in a tinnitus population. METHODS:: Baseline and follow-up data on EQ-5D and HUI mark III of 429 patients of a randomized controlled clinical trial, investigating cost-effectiveness of usual care versus specialized care of tinnitus, were included. Agreement, discriminative power, and responsiveness of the health state description and the utility scores were examined. RESULTS:: Corresponding dimensions of the EQ-5D and HUI mark III showed large correlations; although ceiling effects were more frequently observed in the EQ-5D. Mean utility scores for EQ-5D (0.77; SD 0.22) and HUI mark III (0.64; SD 0.28) were significantly different (Wilcoxon signed ranks test, p < 0.001), and agreement was low to moderate (intraclass correlation coefficient = 0.53). Both health state description and utility scores of both measures discriminated between different severity groups. These groups were based on baseline scores of the Tinnitus Questionnaire. The HUI mark III had a higher ability than the EQ-5D to detect improved patients from randomly selected pairs of improved and unimproved patients. CONCLUSION:: This study shows that different utility measures lead to different health state descriptions and utility scores among tinnitus patients. However, both measures are capable of discriminating between clinically different groups. The HUI mark III is more responsive than the EQ-5D, and therefore preferred in a tinnitus population.
Abstract: OBJECTIVES:: Tinnitus Disability Index (TDI) is presented as a novel and brief self-report measure for the assessment of the interference of tinnitus with performance in specific daily life activities. We hypothesized that the TDI is a reliable and valid measure and that tinnitus disability is strongly associated with tinnitus severity, subjective tinnitus intensity ratings, and ratings of general health. DESIGN:: Six hundred fifteen tinnitus patients from across the Netherlands completed online a number of questionnaires about their tinnitus, their general health, and demographics. Two samples were extracted by a random split: Sample I (N = 311) for exploratory factor analysis and Sample II (N = 304) for confirmatory analysis, using structural equation modeling. One hundred forty-three of the first included respondents repeated assessment after a 2-wk time interval for test/retest analysis. Regression analyses were employed to investigate construct validity. RESULTS:: Present analyses reveal that tinnitus disability, as measured with the TDI, might be best understood as a single-component construct, that is, one single underlying factor. The TDI is reliable over time, and tinnitus-related disability, as measured with the TDI, is strongly associated with subjective ratings of tinnitus intensity, negatively associated with quality of life ratings, and distress due to tinnitus. CONCLUSIONS:: The TDI is a brief and easily administered index measuring a unique construct, namely the experienced interference of the tinnitus with daily life activities, which is invaluable in the assessment and treatment of tinnitus patients.
Abstract: The current review deals with interoceptive conditioning as a viable mechanism maintaining fear of pain: The available literature suggests that interoceptive - i.e., internal bodily - sensations may become predictors of pain and will subsequently elicit fear of pain. After a short overview of interoceptive (fear) conditioning and its role in the maintenance of panic disorder, the existing literature on conditioning in the field of pain and fear of pain is reviewed. Next, the authors propose an interoceptive fear conditioning model of fear of pain, suggesting that bodily sensations can function as predictors of pain and as conditioned stimuli become endowed with the capacity to elicit an (anticipatory) fear response. The review concludes with a number of theoretical and clinical considerations, introducing interoceptive exposure as a potentially effective treatment for fear of pain.
Abstract: It has been proposed that goal pursuit plays a role in the development of chronic pain disorders. On the basis of (affective) motivational theories, it was hypothesized that both long-term achievement goals and short-term hedonic goals would be related to increased levels of pain and disability, particularly in patients with high negative affect. Participants with musculoskeletal pain complaints (N=299) completed a battery of questionnaires including a novel goal pursuit questionnaire (GPQ) measuring the extent to which participants preferred hedonic goals (mood-management or pain-avoidance goals) over achievement goals in various situations. Explorative factor analysis of the GPQ resulted in a reliable pain-avoidance (α=.88) and mood-management subscale (α=.76). A nonlinear, U-shaped relationship was found among the pain-avoidance scale (but not the mood-management scale) and pain and disability. This indicated that participants who strongly endorsed either achievement or pain-avoidance goals also reported higher pain and disability levels while controlling for biographical variables and pain catastrophizing. For pain but not disability, these relationships were only found among patients with high negative affect. For disability, goal pursuit and negative affect were independently related to disability. These findings provide support for the validity of an affective-motivational approach to chronic pain, suggesting that the experience of pain and the interference of pain on daily life activities depends on goal pursuit and negative affect. Interventions aimed at improving disability in chronic pain should address both patient's goal pursuit and negative affect. An affective-motivational approach to chronic pain indicates that achievement and pain-avoidance goals are associated with pain severity and disability, particularly in patients with high negative affect.
Abstract: OBJECTIVES:: It is well established that catastrophic misinterpretations and fear are involved in the suffering and disability of patients with chronic pain. This study investigated whether similar processes explain suffering and disability in patients with chronic tinnitus. We hypothesized that patients who catastrophically (mis)interpret their tinnitus would be more fearful of tinnitus, more vigilant toward their tinnitus, and report less quality of life. Moreover, tinnitus-related fear was expected to act as a mediator in reduced quality of life. DESIGN:: Sixty-one tinnitus patients from an outpatient ENT department of the University Hospital of Antwerp (Belgium) completed a number of questionnaires about their tinnitus. Hierarchical regression analyses were performed to test hypothesized associations and to assess mediation by tinnitus-related fear. RESULTS:: Analyses revealed significant associations between catastrophizing and fear and between catastrophizing and increased attention toward the tinnitus. Furthermore, both tinnitus-related catastrophizing and fear were negatively associated with quality of life; moreover, tinnitus-related fear fully mediated the association between catastrophizing about the tinnitus and quality of life. CONCLUSIONS:: The findings confirm earlier suggestions that tinnitus-related concerns and fears are associated with impaired quality of life, which is in line with a cognitive behavioral account of chronic tinnitus. Future research avenues and clinical applications are discussed.
Abstract: Two studies are reported that tested the fear-avoidance (FA) model using path analytic techniques. In study 1, 429 employees with back pain at baseline and back pain at 18 months follow-up completed questionnaires assessing sociodemographic information, pain severity, negative affect, pain-related fear, and disability. Results indicated that pain severity at baseline predicted pain-related fear and disability at follow-up, and that pain-related fear is rather a consequence than an antecedent of pain severity. Results further revealed that the disposition to experience negative affect has a low impact upon pain severity and disability, and is best viewed as a precursor of pain-related fear. Study 2 included 238 employees without back pain at baseline, but who developed back pain at 1 year follow-up. A similar model as in study 1 was tested. Overall, results are in line with those of study 1. Results are discussed in terms of theoretical relevance and clinical implications.
Abstract: Recurrent pain not only has an impact on disability, but on the long term it may become a threat to one's sense of self. This paper presents a cross-sectional study of patients with work-related upper extremity pain and focuses on: (1) the role of self-discrepancies in this group, (2) the associations between self-discrepancies, pain, emotions and (3) the interaction between self-discrepancies and flexible-goal adjustment. Eighty-nine participants completed standardized self-report measures of pain intensity, pain duration, anxiety, depression and flexible-goal adjustment. A Selves Questionnaire was used to generate self-discrepancies. A series of hierarchical regression analyses showed relationships between actual-ought other, actual-ought self, actual-feared self-discrepancies and depression as well as a significant association between actual-ought other self-discrepancy and anxiety. Furthermore, significant interactions were found between actual-ought other self-discrepancies and flexibility, indicating that less flexible participants with large self-discrepancies score higher on depression. This study showed that self-discrepancies are related to negative emotions and that flexible-goal adjustment served as a moderator in this relationship. The view of self in pain and flexible-goal adjustment should be considered as important variables in the process of chronic pain.
Abstract: Patients with chronic pain are not only faced with disabilities but are also challenged to maintain a valued sense of self. This sense of self is in part determined by the extent to which patients can accomplish their identity-related goals. The present study explores the content of three domains of the self, namely the ideal, ought and feared self and examines how the content relates to disability and depression. The ideal, ought and feared attributes of 80 chronic low back pain patients were analyzed and categorized in eight general goal-domains: interpersonal attributes, personal abilities, physical, emotional and psychological well-being, close interpersonal relationships, self-expression abilities, achievement-related attributes, physical appearance, and religion. Results showed that most of the attributes that patients generated involved interpersonal attributes. Comparisons between the self-guides revealed that ideal attributes were more intrapersonally focused while ought and feared attributes were interpersonally focused. The content appeared to be related to disability but not to depression. More specifically, the more disabled patients were, the more they listed well-being related attributes as part of their ought self. None of the other goal-domains was related to disability or depression. The present study provides additional insight into the goals of patients with chronic pain at the level of identity and has shown that these are, at least in part, related to the level of functional disability. These results might be useful for future studies incorporating the role of identity in chronic pain, such as psychological interventions.
Abstract: This review covers the current cognitive behavioural treatments available to address fear-avoidance beliefs in patients with chronic musculoskeletal pain (CMP). Four types of treatment protocols were identified for inclusion in the review: (a) graded in vivo exposure (GivE); (b) graded activity (GA); (c) acceptance and commitment therapy (ACT); and (d) mixed cognitive behavioural protocols. Most of the research suggests that GivE and ACT result in the best outcomes for treating fear-avoidance beliefs in patients with CMP. There is also a readily apparent paucity of research from North America; indeed, most of the available studies were conducted in the Netherlands and Scandinavia. This relative absence of North American research raises potentially important questions about the role of compensation status and access to care, which differ between countries, on treatment outcome. Implications and directions for future research are discussed.
Abstract: Patients with work-related upper extremity pain (WRUED) experience disability in daily life activities. The factors that influence levels of disability are still unclear. Both excessive avoidance and persistence have been suggested, but the affective and motivational processes that underlie these behaviours have not been scrutinized. This study was aimed at examining the role of current mood and stop rules on physical task performance, controlling for gender, pain severity, pain catastrophizing, and pain-related fear. An additional focus was the role of the interaction between current mood and stop rules as predicted by the novel Mood-as-Input (MAI) model. Following MAI, it is the informational value of current mood within a goal context (stop rule), rather than mood per se that predicts behaviour. A 2 (mood)x2 (stop rule)x2 (physical task order) factorial design was used in which 62 WRUED patients performed an upper and lower extremity physical task. A stress interview was used to induce positive and negative mood. Patients received either an "as-much-as-can (AMAC)" stop rule instruction, or a "feel-like-discontinuing (FLDC)" stop rule instruction. Results showed that physical task performance was predicted by pain-related fear, current mood, stop rule. However, the predicted moodxstop rule interaction was not found, and there was no influence of gender, pain severity, and pain catastrophizing on task performance. The findings suggest that not only pain-related fear, but current mood and goal context factors independently affect physical performance in patients with WRUED.
Abstract: Behavioural treatment is commonly used in the management of chronic low-back pain (CLBP) to reduce disability through modification of maladaptive pain behaviours and cognitive processes. Three behavioural approaches are generally distinguished: operant, cognitive, and respondent; but are often combined as a treatment package.
Abstract: Fatigue is one of the most common and troubling symptoms of multiple sclerosis (MS) and more severe and disabling than fatigue in other somatic populations. Although fatigue seems MS specific, its pathogenesis is still poorly understood.
Abstract: Although fatigue is one of the most common and disabling symptoms in patients with multiple sclerosis (MS), its pathogenesis is still poorly understood and it is difficult to treat. The aim of the current study was to test the assumptions of a cognitive-behavioral model that explains fatigue and physical disability in MS patients, by comparing this approach with a more traditional biomedical approach. Structural equation modeling was applied to a sample of 262 MS patients. Neither the cognitive-behavioral, nor the biomedical model showed an adequate fit of our data. The modification indices supported an integration of both models, which showed a better fit than those of the separate models. This final model, is notable for at least three features: (1) fatigue is associated with depression and physical disability, (2) physical disability is associated with disease severity and fatigue-related fear and avoidance behavior, and (3) catastrophic interpretations about fatigue, fueled by depression, mediated the relationship between fatigue and fatigue-related fear and avoidance behavior. Our results suggest that an integrated approach, including the modification of catastrophic thoughts about fatigue, would be beneficial in the treatment of fatigue in MS patients.
Abstract: Acute pain informs the individual that there is an imminent threat of body damage, and is associated with the urge to escape and avoid. Fear learning takes place when neutral stimuli receive the propensity to predict the occurrence of pain, and when defensive responses are initiated in anticipation of potential threats to the integrity of the body. Fear-avoidance models have been put forward featuring the role of individual differences in catastrophic interpretations of pain in the modulation of learning and avoidance. Based on extensive literature on fear reduction in anxiety disorders; cognitive-behavioral treatments have been developed and applied to patients with chronic pain reporting substantial pain-related fear. In this article, we discuss mechanisms underlying the acquisition, the assessment and extinction of pain-related fear through the cognitive-behavioral treatment of pain-related fear. Finally, we provide a number of critical notes and directions for future research in the field of chronic pain and pain-related fear.
Abstract: Tinnitus is a common chronic health condition that affects 10% to 20% of the general population. Among severe sufferers it causes disability in various areas. As a result of the tinnitus, quality of life is often impaired. At present there is no cure or uniformly effective treatment, leading to fragmentized and costly tinnitus care. Evidence suggests that a comprehensive multidisciplinary approach in treating tinnitus is effective. The main objective of this study is to examine the effectiveness, costs, and cost-effectiveness of a comprehensive treatment provided by a specialized tinnitus center versus usual care. This paper describes the study protocol.
Abstract: Fatigue is a frequent and disabling symptom in patients with multiple sclerosis (MS), but it is difficult to define and measure. Today, MS-related fatigue is not fully understood, and evidence related to explanatory pathophysiological factors are conflicting. Here, we evaluate the contribution of psychological factors to MS-related fatigue. Insight into the possible underlying psychological mechanisms might help us to develop adequate psychological interventions and to improve the overall management of fatigue. Conceptual issues and the relationships between MS-related fatigue and mood, anxiety, cognition, personality, and cognitive-behavioral factors are discussed, and the implications for clinical practice and research are presented.
Abstract: Several treatment principles for the reduction of chronic low back pain associated disability have been postulated. To examine whether a combination of a physical training and operant-behavioral graded activity with problem solving training is cost-effective compared to either alone one year post-treatment, a full economic analysis alongside a randomized controlled trial was conducted. In total 172 patients with chronic disabling non-specific low back pain referred for rehabilitation treatment, were randomized to 10 weeks of aerobic training and muscle strengthening of back extensors (active physical treatment; APT), 10 weeks of gradual assumption of patient relevant activities based on operant-behavioral principles and problem solving training (graded activity plus problem solving training; GAP), or APT combined with GAP (combination treatment; CT). Total costs, existing of direct health and non-health costs and indirect costs due to absence of paid work were calculated by using cost diaries and treatment attendance lists. The Roland Disability Questionnaire was used to calculate the cost-effectiveness to reduce disability and the gain in quality adjusted life year (QALY) by using the EuroQol-5D. APT, followed by CT showed, although not significant, higher total costs than GAP. Reduction of disability and gain in QALY did not differ significantly between CT and the single treatment modalities. Based on the incremental cost effectiveness ratios (ICERs) and cost-effectiveness acceptability curves CT is not cost-effective at all. However, GAP is cost-effective regarding the reduction of disability and gain in QALY, and to a lesser degree APT is more cost-effective than CT in reducing disability.
Abstract: In low back pain (LBP) treatment and research attention has shifted from a biomedical towards a biopsychosocial approach. Patients' LBP beliefs and attitudes were found to predict long-term outcome, and recently it has been suggested that the health care providers' ideas about LBP are also important predictors of treatment behaviour and outcome.
Abstract: Treatment outcome studies ought to assess the fidelity of their treatments, including treatment delivery, but practical guidelines and examples for this are lacking. Based on general recommendations in available literature, this study proposes and illustrates the design and application of a Method of Assessing Treatment Delivery (MATD) in a behavioral medicine trial comparing two treatments for chronic low back pain.
Abstract: Activity pacing has been suggested as a behavioural strategy that may protect patients with fibromyalgia (FM) against activity dysregulation and disability. The aim of the present study was to empirically test whether the construct of activity pacing is distinct from other behavioural strategies assessed with the Chronic Pain Coping Inventory (CPCI), such as guarding, resting, asking for assistance, relaxation, task persistence, exercise/stretch, seeking social support, and coping self-statements. The second objective was to test whether pacing was associated with physical disability when controlling for pain catastrophizing, pain severity and the other behavioural strategies as measured with CPCI. A random sample of patients with FM (N=409) completed the CPCI, the Pain Catastrophizing Scale (PCS), the Physical Index of the Fibromyalgia Impact Questionnaire (FIQ-PH) and the Pain Disability Index (PDI). The results demonstrated that the Dutch version of the CPCI including the pacing subscale has adequate internal consistency and construct validity. Moreover, guarding and asking for assistance, but not pacing, were associated with disability. These findings are in line with fear-avoidance models and suggest that specifically active avoidance behaviours are detrimental in FM. The authors recommend developing cognitive-behavioural and exposure-based interventions and challenge the idea that pacing as an intervention is essential in pain self-management programs.
Abstract: Research has identified several anxiety and fear constructs that contribute directly or indirectly to the chronic course of pain. One way to gain insight into the frequently observed interrelations between these constructs may be by conceptualizing them within a hierarchical structure. In this structure, general and specific constructs are proposed at different levels of a hierarchical tree. The present study sought to find evidence for this idea by exploring the dimensional and componential structure of a hierarchical representation of pain-related anxiety constructs. Small cards describing the individual items of 9 pain-related anxiety measures were presented to undergraduate students (N = 294), who were asked to sort them into piles of what they perceived as items of similar meaning. Cluster analysis (additive tree analyses) revealed cluster groups that could be interpreted along the lines of the proposed hierarchical structure. Multidimensional scaling analysis showed that the similarity data are characterized by a dimension that runs from general affective to pain-specific concerns. This study thus offers empirical support for the postulation of a general and specific hierarchical ordering of these constructs. Furthermore, its results endorse the independent use of various pain-related anxiety measures in research and practice aiming to assess negative emotional constructs that contribute to pain.
Abstract: Current theoretical models of pain catastrophizing have diverging predictions regarding the role of social context and perceived threat on pain expression. The communal coping model of catastrophizing predicts that high pain catastrophizers display more pain expression in the presence of another, regardless of the threat value of the pain, while a cognitive appraisal model predicts high pain catastrophizers to express more pain when pain has increased threat value, regardless of social context. A 2 x 2 factorial design was used to test the validity of both predictions. Healthy participants with varying levels of pain catastrophizing were exposed to a cold pressor task, consisting of a 60 s immersion and 60 s recovery period. Interestingly, the immersion results revealed that beyond and independent from the effects of pain catastrophizing, the effect of threat on verbal pain report and facial expression was dependent on social context and vice versa. In a threatening context, perceived threat of pain mediated the inhibitory effect of social presence on pain expression, suggesting that the observer acted as a safety signal. In the recovery period, social presence enhanced facial expression, but only when no threat was induced. The results are discussed in terms of the dynamic interaction between social context and threat appraisals.
Abstract: How and when concerns about falls emerge is not yet completely known, because these concerns are present in both people with and without a falls history. The aim of this study was to investigate the role of catastrophic beliefs about falls and previous falls in the development of concerns about falls and resulting mobility restrictions (MR).
Abstract: Pain-related fear is related to disability in persistent pain conditions. Exposure treatment has been reported to be of great benefit in replicated single case experiments.
Abstract: Several treatment principles for the reduction of chronic low back pain associated disability have been postulated. To examine whether a combination of a physical training and an operant-behavioral graded activity with problem solving training is more effective than either alone in the long-term, a cluster randomized controlled trial was conducted. In total 172 patients, 18-65 years of age, with chronic disabling non-specific low back pain referred for rehabilitation treatment, were randomized in clusters of four consecutive patients to 10 weeks of aerobic training and muscle strengthening of back extensors (active physical treatment; APT), 10 weeks of gradual assumption of patient relevant activities based on operant-behavioral principles and problem solving training (graded activity plus problem solving training; GAP), or APT combined with GAP (combination treatment; CT). The primary outcome was the Roland Disability Questionnaire adjusted for centre of treatment, cluster, and baseline scores. Secondary outcomes were patients' main complaints, pain intensity, self-perceived improvement, depression and six physical performance tasks. During the one-year follow-up, there were no significant differences between each single treatment and the combination treatment on the primary outcome, the Roland Disability Questionnaire. Among multiple other comparisons, only one significant difference emerged, with GAP and APT showing higher self-perceived improvement than CT. We conclude that the combination treatment integrating physical, graded activity with problem solving training is not a better treatment option for patients with chronic low back pain.
Abstract: Since pain-related fear may contribute to the development and maintenance of chronic low back pain (CLBP), an exposure in vivo treatment (EXP) was developed for CLBP patients. We examined the effectiveness as well as specific mediating mechanisms of EXP versus operant graded activity (GA) directly and 6 months post-treatment in a multi-centre randomized controlled trial. In total, 85 patients suffering from disabling non-specific CLBP reporting at least moderate pain-related fear were randomly allocated to EXP or GA. It was demonstrated that EXP, despite excelling in diminishing pain catastrophizing and perceived harmfulness of activities, was equally effective as GA in improving functional disability and main complaints, although the group difference almost reached statistical significance favouring EXP. Both treatment conditions did not differ in pain intensity and daily activity levels either. Nor was EXP superior to GA in the subgroup of highly fearful patients. Irrespective of treatment, approximately half the patients reported clinically relevant improvements in main complaints and functional disability, although for the latter outcome the group difference was almost significant favouring EXP. Furthermore, the effect of EXP relative to GA on functional disability and main complaints was mediated by decreases in catastrophizing and perceived harmfulness of activities. In sum, this study demonstrates that up to 6 months after treatment EXP is an effective treatment, but not more effective than GA, in moderately to highly fearful CLBP patients, although its superiority in altering pain catastrophizing and perceived harmfulness of activities is clearly established. Possible explanations for these findings are discussed.
Abstract: Bed rest has been shown to be an ineffective treatment for non-specific low back pain (LBP). Despite this, during a new episode of pain some patients still rely on bed rest. Which patients choose bed rest is however unknown. The objectives of the present study were, firstly, to assess characteristics of patients choosing bed rest in (sub)acute pain and secondly to study whether prolonged bed rest in the (sub)acute phase of pain will result in long term disability. A prospective longitudinal cohort study included 282 patients with non-specific LBP for less than 7 weeks. Main outcome measures were duration of bed rest (in three categories) and disability. Results showed that 33% of patients with (sub)acute LBP had bed rest, but only 8% stayed in bed for more than four days. An ordinal regression analysis revealed that behavioural factors (catastrophizing (OR=1.05 per bed rest category p<0.01)) and fear of injury (OR=1.05 per category p<0.01) rather than specific pain related factors (pain history (OR=0.61 per category p=0.16) and pain intensity (OR=1.00 per category p=0.63)) were associated with bed rest. Patients with prolonged bed rest in an early phase of pain were still more disabled after one year (p<0.01). Based on these results we conclude that prolonged bed rest in the early phase of pain is associated with a higher long term disability level. In preventing low back disability, GP screening for catastrophizing and fear of injury in LBP patients who had prolonged bed rest merits consideration.
Abstract: For patients with acute post-traumatic neck pain (PTNP), pain-related fear has been identified as a potential predictor of chronic disability. If such is the case, fear reduction should enhance the prevention of further pain disability and distress after traumatic neck pain disability. However, exposure-based treatments have not been tested in patients with PTNP. Using a replicated single-case crossover phase design with multiple measurements, this study examined whether the validity of a graded exposure in vivo, as compared with usual graded activity, extends to PTNP. Eight patients who reported substantial pain-related fear were included in the study. Daily changes in pain intensity, pain-related fear, pain catastrophizing, and activity goal achievement were assessed. Before and after each intervention, and at 6-month follow-up, standardized questionnaires of pain-related fear and pain disability were administered, and, to quantify daily physical activity level, patients carried an ambulatory activity monitor. The results showed decreasing levels of self-reported pain-related fear, pain intensity, disability, and improvements in physical activity level only when graded exposure in vivo was introduced, and not in the graded activity condition. The results are discussed in the context of the search for customized treatments for PTNP. PERSPECTIVE: This is the first study showing that the effects of graded exposure in vivo generalize to patients with chronic PTNP reporting elevated levels of pain-related fear. This could help clinicians to customize treatments for PTNP.
Abstract: Previous research supports the fear-avoidance model in explaining the transition from acute to chronic non-specific musculoskeletal pain. However, there is still little knowledge on when this vicious circle of pain, disability, pain catastrophizing and fear of movement starts. We performed a daily diary study in 42 patients with acute whiplash injury. Pain, disability, pain catastrophizing and fear of movement were measured on a daily basis with paper diaries for 21 consecutive days. Most participants showed a decline in pain and disability from day 1 to day 21 and this was paralleled by a decline in the fear of movement and pain catastrophizing. Multilevel analyses showed that both between and within persons, high levels of pain catastrophizing and fear of movement are associated with more pain and disability. Moreover, the fear of movement was also predictive of pain and disability on the following day. We also examined the reverse association, that is, whether the changes in pain predict changes in the next day's fear of movement and pain catastrophizing. Although for the fear of movement the model reached significance, the amount of explained variance was negligible. In conclusion, this study provides evidence that already in the early stages of whiplash-related complaints, significant associations between fear of movement and pain intensity and disability occur, and that this association may be predictive of the persistence of pain.
Abstract: Pregnancy-related low back pain is considered an important health problem and potentially leads to long-lasting pain and disability. Investigators draw particular attention to biomedical factors but there is growing evidence that psychosocial and social factors might be important. It prompted us to start a large cohort study (n = 7526) during pregnancy until one year after delivery and a nested randomized controlled intervention study in the Netherlands.
Abstract: Patients' initial beliefs about the success of a given pain treatment are shown to affect final treatment outcome. The Credibility/Expectancy Questionnaire (CEQ) has recently been developed as measure of treatment credibility and expectancy.
Abstract: Research studies focusing on the fear-avoidance model have expanded considerably since the review by Vlaeyen and Linton (Vlaeyen J. W. S. & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain, 85(3), 317--332). The fear-avoidance model is a cognitive-behavioral account that explains why a minority of acute low back pain sufferers develop a chronic pain problem. This paper reviews the current state of scientific evidence for the individual components of the model: pain severity, pain catastrophizing, attention to pain, escape/avoidance behavior, disability, disuse, and vulnerabilities. Furthermore, support for the contribution of pain-related fear in the inception of low back pain, the development of chronic low back pain from an acute episode, and the maintenance of enduring pain, will be highlighted. Finally, available evidence on recent clinical applications is provided, and unresolved issues that need further exploration are discussed.
Abstract: Using the data of the EuroBack Unit prospective cohort study, this paper investigated the role of work-related physical factors and psychological variables in predicting the development of and recovery from short-term and long-term LBP. At baseline, 1294 predominantly male industrial workers from 10 companies in Belgium and the Netherlands filled in questionnaires. At follow-up, data from 812 employees were available. Odds ratios (ORs) were calculated using simple and multiple logistic regression analyses. For those workers reporting 0 days LBP in the year prior to baseline, negative affectivity (OR 1.06, 95% CI 1.01-1.11) was a risk factor for the development of short-term LBP (=1-30 days total of LBP in the year prior to follow-up). For those who reported 1-30 days total of LBP in the year prior to baseline, only high fear of (re)injury due to movement (OR 1.07, 95% CI 1.02-1.12) increased the risk for failure to recovery from short-term LBP. For the development of long-term LBP (=more than 30 days total of LBP in the year prior to follow-up), a significant increased risk was observed among workers with high pain severity (OR 1.19, 95% CI 1.01-1.40) and with pain referred to the ankles or feet (OR 2.92, 95% CI 1.09-7.83). The risk was reduced by social support of co-workers (OR 0.73, 95% CI 0.59-0.92) and by manual handling of materials (OR 0.63, 95% CI 0.46-0.85). For those who reported more than 30 days total of LBP in the year prior to baseline, high pain severity (OR 1.18, 95% CI 1.04-1.34) increased the risk for failure to recovery from long-term LBP. Results are compared to the baseline study (Gheldof et al., 2005) and discussed in relation with prospective studies.
Abstract: Previous studies using a primary task procedure have demonstrated that an experimental pain stimulus interrupts ongoing task performance in healthy volunteers and patients, and that this interruption is intensified by catastrophic thinking about pain and the perceived threat value of the pain stimulus. However, no studies have investigated the interruption of attention by relevant threatening stimuli in specific patient samples. In the present study, 40 patients with chronic whiplash syndrome and 40 healthy controls performed a primary task while simultaneously a potentially threatening neck fixation (i.e., extension and rotation) was imposed. Pain catastrophizing, fear of movement/(re)injury, hypervigilance, and depression were assessed. The patients showed a more pronounced deterioration of performance compared to controls when the neck rotation and extension fixations were introduced. Within the groups, neither catastrophic thinking nor fear predicted the magnitude of the performance deterioration.
Abstract: 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.
Abstract: The aims of the current study were twofold. First, the factor structure, reliability (i.e., internal consistency), and validity (i.e., concurrent criterion validity) of the Tampa Scale for Kinesiophobia (TSK), a measure of fear of movement and (re)injury, were investigated in a Dutch sample of patients with work-related upper extremity disorders (study 1). More specifically, examination of the factor structure involved a test of three competitive models: the one-factor model of all 17 TSK items, a one-factor model of the TSK (Woby SR, Roach NK, Urmston M, Watson P. Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain 2005;117:137-44.), and a two-factor model of the TSK-11. Second, invariance of the aforementioned TSK models was examined in patients with chronic musculoskeletal pain conditions (i.e., work-related upper extremity disorders, chronic low back pain, fibromyalgia, osteoarthritis) from The Netherlands, Sweden, and Canada was assessed (study 2). Results from study 1 showed that the two-factor model of the TSK-11 consisting of 'somatic focus' (TSK-SF) and 'activity avoidance' (TSK-AA) had the best fit. The TSK factors showed reasonable internal consistency, and were modestly but significantly related to disability, supporting the concurrent criterion validity of the TSK scales. Results from study 2 showed that the two-factor model of the TSK-11 was invariant across pain diagnoses and Dutch, Swedish, and Canadian samples. Altogether, we consider the TSK-11 and its two subscales a psychometrically sound instrument of fear of movement and (re)injury and recommend to use this measure in future research as well as in clinical settings.
Abstract: Fear of movement/(re)injury is assumed to contribute to the development and maintenance of chronic low back pain (CLBP) in a subgroup of patients. Studying fear of movement/(re)injury with implicit attitude measures, without the awareness of the patient, might be a valuable addition to self-report questionnaires. The aims of the current study were to investigate whether CLBP patients demonstrate more implicit fear of movement/(re)injury than healthy controls, and whether 2 implicit measures are related to each other, and to an explicit self-report measure of fear of movement/(re)injury. A group of 66 CLBP patients and 30 healthy controls took part in this study. In addition to self-report questionnaires, fear of movement/(re)injury was implicitly assessed by the Extrinsic Affective Simon Task (EAST) and the Go-No-Go-Association Task (GNAT) that aimed to determine the association between back-stressing movements and the evaluation "threatening". On both implicit tasks it was found that neither CLBP patients nor healthy controls demonstrated implicit fear of movement/(re)injury, and that CLBP patients did not differ from healthy controls in their level of implicit fear of movement/(re)injury. In general, no associations were found between the EAST and the GNAT, or between implicitly measured and self-reported fear of movement/(re)injury. One major caveat in drawing inferences from these findings is the poor reliability of these implicit measures. Research towards the psychometric properties of these measures should first be expanded before modifying, and applying, them to more complex domains such as fear of movement/(re)injury.
Abstract: To identify somatic and psychologic predictors of pain, functional limitations, global perceived recovery, and quality of life 6 months after surgical intervention.
Abstract: The Tampa Scale for Kinesiophobia (TSK) and the Fear-Avoidance Beliefs Questionnaire (FABQ) are frequently used questionnaires for pain-related fear, and the visual analogue scale (VAS) is for pain.
Abstract: Cognitive-behavioral models of chronic low back pain (CLBP) predict that dysfunctional assumptions about the harmfulness of activities may maintain pain-related fear and disability levels. The Photograph Series of Daily Activities (PHODA) is an instrument to determine the perceived harmfulness of daily activities in patients with CLBP. This study examined the psychometric properties of a short electronic version of the PHODA (PHODA-SeV). The results show that the PHODA-SeV measures a single factor and has a high internal consistency. The test-retest reliability and stability of the PHODA-SeV over a 2-week time interval are good, with discrepancies between 2 measurements over 20 points suggesting true change. The construct validity is supported by the finding that both self-reported pain severity and fear of movement/(re)injury were uniquely related to the PHODA-SeV. Validity is further corroborated by the finding that patients who have received exposure in vivo, that aimed to systematically reduce the perceived harmfulness of activities, had significantly lower PHODA-SeV scores after treatment than patients receiving graded activity that did not address these assumptions. The findings support the PHODA-SeV as a valid and reliable measure of the perceived harmfulness of activities in patients with CLBP. Preliminary normative data of the PHODA-SeV are presented. PERSPECTIVE: This article describes a pictorial measurement tool (PHODA-SeV) for the assessment of the perceived harmfulness of activities in patients with chronic low back pain. The PHODA-SeV has good psychometric properties and can be used to elaborate on the contribution of beliefs about harmful consequences of activities to pain and disability.
Abstract: For years, physical deconditioning has been thought to be both a cause and a result of back pain. As a consequence physical reconditioning has been proposed as treatment-goal in patients with chronic low back pain (LBP). However, it is still unclear whether a patient's physical fitness level really decreases after pain-onset. The objectives of the present study were, firstly, to test the assumption that long-term non-specific LBP leads to a decrease of the level of physical activity (disuse), secondly, to evaluate any development of physical deconditioning as a result of disuse in CLBP, and thirdly, to evaluate predictors for disuse in CLBP. A longitudinal cohort study over one year including 124 patients with sub-acute LBP (i.e., 4-7 weeks after pain onset) was performed. Main outcome measures were change in physical activity level (PAL) and physical fitness (measured by changes in body weight, body fat and muscle strength) over one year. Hypothesized predictors for disuse were: pain catastrophizing; fear of movement; depression; physical activity decline; the perceived level of disability and PAL prior to pain. Results showed that only in a subgroup of patients a PAL-decrease had occurred after the onset of pain, whereas no signs of physical deconditioning were found. Negative affect and the patients' perceived physical activity decline in the subacute phase predicted a decreased level of PAL over one year. Based on these results, we conclude that as to the assumption that patients with CLBP suffer from disuse and physical deconditioning empirical evidence is still lacking.
Abstract: The treatment of non-specific chronic low back pain is often based on three different models regarding the development and maintenance of pain and especially functional limitations: the deconditioning model, the cognitive behavioral model and the biopsychosocial model. There is evidence that rehabilitation of patients with chronic low back pain is more effective than no treatment, but information is lacking about the differential effectiveness of different kinds of rehabilitation. A direct comparison of a physical, a cognitive-behavioral treatment and a combination of both has never been carried out so far.
Abstract: For the moment, scientific evaluation of programs on treatment of pregnancy-related pelvic girdle and/or low back pain after delivery is hardly available with only one study with a positive result, suggesting uncertainty about the optimal approach. Investigators draw particular attention to biomedical factors but there is growing evidence that biopsychosocial factors appear to be even more important as a basis of an intervention program.
Abstract: Pain-related fear and pain catastrophizing are associated with disability and actual performance in chronic pain patients. In acute low back pain (LBP), little is known about the prediction of actual performance or perceived disability by pain-related fear and pain catastrophizing. This experimental, cross-sectional study aimed at examining whether pain-related fear and pain catastrophizing were associated with actual performance and perceived disability. Ninety six individuals with an episode of acute LBP performed a dynamic lifting task to measure actual performance. Total lifting time was used as outcome measure. The results show that pain-related fear, as measured with the Tampa Scale for Kinesiophobia, was the strongest predictor of this physical task. Using the Roland Disability Questionnaire as a measure of perceived disability, both pain-related fear and pain catastrophizing, as measured with the Pain Catastrophizing Scale, were significantly predictive of perceived disability and more strongly than pain intensity was. The results of the current study suggest that pain-related fear is an important factor influencing daily activities in individuals suffering an episode of acute LBP. The study results have important clinical implications, especially in the development of preventive strategies for chronic LBP.
Abstract: Fear-avoidance beliefs have been shown to be associated with disability and work status in patients with low back pain. Especially in acute low back pain, much research is needed to increase the knowledge concerning the role of fear-avoidance beliefs and its associated avoidance behavior in the influence on disability and the participation in daily and social life activities. The Fear-Avoidance Beliefs Questionnaire is developed to measure such beliefs and has become increasingly popular for use in primary care practice. The aim of the current study was: 1) to investigate the factor structure of the Fear-Avoidance Beliefs Questionnaire in a population of patients with acute low back pain by means of confirmatory factor analysis; 2) to examine the relationship between fear-avoidance beliefs and perceived disability, as well as participation in daily and social life; and 3) to investigate whether perceived disability mediates the association between pain and participation and between fear-avoidance beliefs and participation.
Abstract: This study examined the role of work-related, psychosocial and psychological factors in predicting functional and social disability in working employees. In a cross-sectional design, 890 working employees (reporting at least 1 day of back pain during the past year) completed self-report measures of back pain, disability, pain-related fear, negative and positive affectivity, job satisfaction, job stress and physical work load. Regression analyses revealed that pain intensity was a strong predictor of functional (beta = .69, p < .001) and social disability (beta = .67, p < .001). Fear of (re)injury due to movement (beta = .25, p < .001; beta = .28, p < .001) had additional predictive value in both models. Further, (singular) mediation tests indicated that fear for (re)injury partially mediated the relation between pain intensity and disability, and between negative affectivity and disability. Finally, path analyses revealed both fear and pain intensity as mediators between negative affectivity and disability. Overall, our findings point at the relevance of the cognitive-behavioral model of avoidance in occupational settings.
Abstract: Does physical deconditioning (loss of cardiovascular capacity and strength/endurance of paraspinal muscles) exist in patients with chronic low back pain (CLBP) and are treatments specifically aimed to reduce these signs effective?
Abstract: The present study examined the effects of a manipulation of attention to pain (i.e. attentional focusing vs. distraction) on pain intensity in daily life of patients with chronic low back pain. It was hypothesized that attentional focusing would lead to decreased pain intensity in high pain fearful individuals, whereas distraction from pain would be associated with decreased pain intensity in low pain fearful individuals.
Abstract: The aim of this study was to examine whether treatments based on different theories change pain catastrophizing and internal control of pain, and whether changes in these factors mediate treatment outcome. Participants were 211 patients with nonspecific chronic low back pain (CLBP) participating in a randomized controlled trial, attending active physical treatment (APT, n = 52), cognitive-behavioral treatment (CBT, n = 55), treatment combining the APT and CBT (CT, n = 55), or waiting list (WL, n = 49). Pain catastrophizing decreased in all 3 active treatment groups and not in the WL. There was no difference in the change in internal control across all 4 groups. In all the active treatment groups, patients improved regarding perceived disability, main complaints, and current pain at post-treatment, and no changes were observed in the WL group. Depression only changed significantly in the APT group. Change in pain catastrophizing mediated the reduction of disability, main complaints, and pain intensity. In the APT condition, pain catastrophizing also mediated the reduction of depression. Not only cognitive-behavioral treatments but also a physical treatment produced changes in pain catastrophizing that seemed to mediate the outcome of the treatment significantly. The implications and limitations of these results are discussed. PERSPECTIVE: This article shows that treatment elements that do not deliberately target cognitive factors can reduce pain catastrophizing. Reduction in pain catastrophizing seemed to mediate the improvement of functioning in patients with chronic low back pain. The results might contribute to the development of more effective interventions.
Abstract: Behavioural treatment, commonly used in the treatment of chronic low-back pain (CLBP), is primarily focused at reducing disability through the modification of environmental contingencies and cognitive processes. In general, three behavioural treatment approaches are distinguished: operant, cognitive and respondent.
Abstract: By elaborating on previous prospective and cross-sectional research, the primary aim of this study was to examine in the general community whether pain catastrophizing predicts the development of chronic pain complaints and other consequences of pain. The following health index values were examined as consequences of pain: specialist consultation, use of pain medication, and absenteeism. It was also examined whether these relationships were moderated by the number of pain problems and by pain intensity. The results demonstrated a generally low level of catastrophizing and a small but significant effect of catastrophizing on the development of chronic pain complaints. With respect to the health index values, no significant effects of catastrophizing were found, nor were the relationships between catastrophizing and chronicity and the health index values moderated by the number of pain problems or by pain intensity. PERSPECTIVE: Because in the general community the level of catastrophizing is low, its role in the development of future pain problems is probably limited in this type of setting. More practically, the Pain Catastrophizing Scale, used to measure pain catastrophizing, is probably of limited use as a screening instrument in the general community. The disappointing results may indicate that, depending on the specific setting (eg, clinical, outpatient, or community) the role of pain catastrophizing is either more or less prominent.
Abstract: Physical as well as psychological features might be important prognostic factors for residual complaints following lumbar disc surgery in primary care. No studies have yet investigated both factors simultaneously. The aim of this prospective cohort study was to identify indicators of the short and long-term outcome of residual complaints following lumbar disc surgery. Patients (n=105), aged between 18 and 65 years, were included if they still suffered residual complaints 6 weeks after first-time lumbar disc surgery and had therefore been referred to physiotherapy. All potential indicators were measured at baseline except treatment expectancy, which was measured after two treatment sessions enabling patients to rate treatment expectancy based on their actual perception of the treatment. Dimensions of recovery included perceived recovery, functional status, and pain intensity (back and leg) at the 3-month and 12-month follow-up. It was found that high treatment expectancy was associated with a favorable outcome on perceived recovery and functional status, both at the 3 and the 12-month follow-up. Taking pain medication and a poor functional status at baseline were associated with poor perceived recovery and functional status at both follow-up measurements. Leg pain and back pain at baseline were associated with residual leg and back pain at the 3 and the 12-month follow-up, respectively. The results for perceived recovery and functional status were rather robust. However, for leg pain and back pain, the results were less stable. Apparently, the clinical course to recovery of residual leg pain and residual back pain is not strongly influenced by these indicators.
Abstract: The objectives of this study were to investigate pain cognitions and quality of life of chronic pain patients referred to a multi-disciplinary university pain management clinic and to search for predictors of quality of life.
Abstract: The Pain Attitudes and Beliefs Scale for Physiotherapists (PABS-PT) differentiates between a biomedical versus a biopsychosocial treatment orientation with regard to common low back pain. This study re-examined the factor structure and psychometric properties of the PABS-PT, along with the relationship between PABS-PT scores and the perceived harmfulness of physical activities and treatment recommendations for common low back pain. Two hundred and ninety-seven paramedical therapists completed the PABS-PT and questionnaires measuring related concepts, rated the perceived harmfulness of 41 daily physical activities depicted in photographs and gave recommendations for return to normal activity for three patients with low back pain. Analysis revealed two factors labelled 'biomedical' and 'biopsychosocial treatment orientation'. Furthermore, scores on both factors of the PABS-PT were related to measures of related concepts (statistically significant Pearson correlation coefficients between 0.30 and 0.65) such as the HC-PAIRS and a therapist version of the TSK. Regression analyses revealed that both factors were consistent predictors of judgements of the harmfulness of physical activities (PHODA) and of recommendations for return to work and normal activity.
Abstract: Clinical research of graded exposure in vivo with behavioral experiments in patients with chronic low back pain who reported fear of movement/(re)injury shows abrupt changes in self-reported pain-related fears and cognitions. The abrupt changes are more characteristics of insight learning rather than the usual gradual progression of trial and error learning. The educational session at the start of the exposure might have contributed to this insight. The current study examines the contribution of education and graded exposure versus graded activity in the reduction of pain-related fear and associated disability and physical activity. 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, all the patients received a single educational session, followed again by a no-treatment period. Patients were then randomly assigned to either a graded exposure with behavioral experiments or an operant graded activity program. A diary was used to assess daily changes in pain intensity, pain-related fear, pain catastrophizing, and activity goal achievement. Standardized questionnaires of pain-related fear, pain vigilance, pain intensity, and pain disability were administered before and after each intervention and at the 6-month follow-up. An activity monitor was carried at baseline, during the interventions, and 1 week at 6-month follow-up. Randomization tests of the daily measures showed that improvements in pain-related fear and catastrophizing occurred after the education was introduced. The results also showed a further improvement when exposure in vivo followed the no-treatment period after the education and not during the operant graded activity program. Performance of relevant daily activities, however, were not affected by the educational session and improved significantly only in the exposure in vivo condition. All improvements remained at half-year follow-up only in patients receiving the exposure in vivo. These patients also reported a significant decrease in pain intensity at follow-up.
Abstract: Since the introduction of behavioral medicine in the early 70s, cognitive-behavioral treatment interventions for chronic pain have expanded considerably. It is now well established that these interventions are effective in reducing the enormous suffering that patients with chronic pain have to bear. In addition, these interventions have potential economic benefits in that they appear to be cost-effective as well. Despite these achievements, there is still room for improvement. First, there is a substantial proportion of patients who do not appear to benefit from treatment interventions available. Second, although the effect sizes of most cognitive-behavioral treatments for chronic pain are comparable to those in psychopathology, they are quite modest. Third, there is little evidence for differential outcomes for different treatment methods. Fourth, there still is relatively little known about the specific biobehavioral mechanisms that lead to chronic pain and pain disability. One direction is to better match treatment programs to patients' characteristics. This can be done according to an "Aptitude X Treatment Interaction" framework, or from the perspective of the Moderator-Mediator distinction. In this introduction to the special series on what works for whom in cognitive-behavioral treatments for chronic pain, we review existing knowledge concerning both moderating and mediating variables in cognitive-behavioral treatments for chronic pain. We further argue in favor of theory-driven research as the only way to define specific a priori hypotheses about which patient-treatment interactions to expect. We also argue that replicated single-participant studies, with appropriate statistics, are likely to enhance new developments in this clinical research area.
Abstract: To evaluate muscle strength, as a component of physical deconditioning, and central activation ratio, representing the performance level during testing, in patients with chronic low back pain as compared to healthy controls, and to evaluate the contribution of cognitive-behavioral and pain-related factors to the central activation ration of patients with chronic low back pain.
Abstract: Patients' initial beliefs about the success of a given pain treatment are shown to have an important influence on the final treatment outcome. The aims of the paper are to assess determinants of patients' treatment expectancy and to examine the extent to which treatment expectancy predicts the short-term and long-term outcome of cognitive-behavioral treatment of chronic pain. This study employs the data of 2 pooled randomized clinical trials evaluating the effectiveness of cognitive-behavioral interventions for 171 patients with fibromyalgia and chronic low back pain. Pretreatment and posttreatment expectancy were measured by a short questionnaire, which was based on the procedure by Borkovec and Nau. Four composite outcome variables (pain coping and control, motoric behavior, negative affect, and quality of life) were measured before and after the intervention and at 12 months follow-up. Furthermore, several patient characteristics were taken into account. Patients with higher treatment expectancies significantly received less disability compensation and were less fearful. A regression model of 3 factors (better pain coping and control, active and positive interpretation of pain, and less disability compensation) significantly explained 10% of the variance in pretreatment expectancy. Pretreatment expectancy significantly predicted each of the 4 outcome measures immediately after treatment and at 12 months follow-up. This study corroborates the importance of treatment expectation before entering a cognitive-behavioral intervention in patients with chronic musculoskeletal pain.
Abstract: The present study examined the contribution of physical pathology, pain-related fear and catastrophizing cognitions to pain intensity and disability in 100 patients with non-specific low back pain. Self-report instruments were completed as part of the intake procedure of patients, while physical pathology was quantified from medical charts using the MEDICS procedure. Results of the multiple regression analyses, adjusted for relevant demographic variables, pain intensity and pain duration, indicated that physical pathology was associated with pain intensity, but not with self-reported physical disability. Disability showed the strongest association with pain intensity. However, pain-related fear and catastrophizing contributed 4-10% additional explained variance to the regression models for pain intensity and disability. Thus, this study confirms the relationship between biological and psychological variables in determining the severity of low back pain complaints, and underscores the necessity for a multidisciplinary approach to diagnostics and intervention.
Abstract: This cross-sectional questionnaire study investigated the role of pain (pain severity, radiating pain), work characteristics (physical workload, job stressors, job satisfaction), negative affect and pain-related fear in accounting for low back pain (LBP) and sick leave (SL) in 1294 employees from 10 companies in Belgium and the Netherlands. An increased risk for short-term LBP (1-30 days during the last year) was observed for workers reporting high physical workload (OR=2.39), high task exertion (OR=1.63) and high negative affect (OR=1.03). For prolonged LBP (>30 days during the last year) severe pain (OR=13.03), radiating pain (OR=2.37) and fear of work-related activities (OR=3.17) were significant risk factors. A lack of decision latitude decreased the risk of long-term LBP (OR=0.39). Short-term SL (1-30 days during the last year) was associated with severe pain (OR=2.83), high physical workload (OR=2.99) and high fear of movement/(re)injury (OR=1.88). A lack of decision latitude increased the risk of short-term SL (OR=1.92). Long-term SL (>30 days during the last year) was associated with radiating pain (OR=3.80) and high fear of movement/(re)injury (OR=6.35). A lack of co-worker support reduced the risk of long-term SL (OR=0.27). These results suggest that physical load factors are relatively more important in the process leading to short-term LBP and short-term SL, whereas job stressors, severe pain, radiation, and pain-related fear are more important in determining the further course and maintenance of the inability to work. The potential implications of these findings for primary and secondary prevention, and occupational rehabilitation are discussed.
Abstract: The current study aimed to measure the differential predictive value of implicit and explicit attitude measures on treatment behaviour of health care providers. Thirty-six physiotherapy students completed a measure of explicit treatment attitude (Pain Attitudes And Beliefs Scale For Physiotherapists-PABS-PT) and a measure of implicit treatment attitude (Extrinsic Affective Simon Task-EAST). Furthermore, they gave treatment recommendations for a patient simulating back pain on three video scenes. The implicit and explicit measures of attitudes were only weakly related to each other. However, both were differentially related to treatment recommendations. The implications of the differential predictive value of implicit and explicit attitude measures for treatment behaviour are discussed.
Abstract: The present study examined the role of personal relevance of sensory pain-related words in selective attentional processing measured with a modified Stroop task administered to 30 patients with chronic low back pain. A related aim of this study was to introduce the application of multilevel analysis to test the influence of personal relevance on selective attentional processing in this sample. Patients completed the modified Stroop task, as well as a set of self-report measures aimed to assess Fear of Pain, Trait Anxiety, Catastrophizing, Pain Vigilance, and Pain Intensity. The modified Stroop task comprised 33 sensory pain-related words for which the personal relevance towards current concerns was rated afterwards by each participant on a 7-point Likert-type scale. The multilevel analyses did not support the hypothesis that personal relevance of sensory pain-related words interacted with Fear of Pain scores of patients in accounting for reaction times in naming the color of sensory pain-related words. None of the other self-report measures accounted for reaction times in isolation or in interaction with personal relevance. The modified Stroop task does not appear to be a robust measure of selective attentional processing in patients with chronic low back pain. The usefulness of other paradigms, such as the visual dot-probe task, should be explored in examining selective attentional processing in this population.
Abstract: The present study sought to examine psychometric properties of the Fear of Pain Questionnaire (FPQ), a measure of pain-related fear, in a sample of undergraduates. Confirmatory factor analysis confirmed the previously reported three-factor model of the FPQ (e.g. severe pain, minor pain, medical pain), but some items may be redundant. With respect to the reliability of the FPQ, both the FPQ and the subscales showed good internal consistency and test-retest stability was moderate to good. Convergent and predictive validity of the FPQ (and the subscales) were partly supported by moderate correlations with related constructs and with self-reported fear associated with three experimental pain tests. Discriminant validity of the FPQ (and the subscales) was partly supported by low correlations with unrelated self-report measures. Moreover, modest correlation coefficients were found between the FPQ and other pain-related measures. Finally, the minor pain subscale of the FPQ accounted for pain intensity scores on the ischemic pain test and the remaining subscales and the FPQ total scores accounted for pain tolerance on the electrical stimulation test and the thermal pain test. Results are discussed and directions for future research are provided.
Abstract: In recent years, several studies have pointed out the importance of pain-related fear in the development and maintenance of chronic pain. An important instrument for measuring pain-related fear in the context of low back pain is the Tampa Scale for Kinesiophobia (TSK). Recently, a version of this questionnaire has been developed for administration among the general population (TSK-G). To determine the factor structure of the TSK-G, data from a random sample of the Dutch general population were studied separately for people who had had back complaints in the previous year, and people who had been without back complaints. For both groups the TSK-G appeared to consist of one, internally consistent, factor of 12 items. The one-factor TSK-G also appeared valid after comparison with scores on measures of catastrophizing and general health status.
Abstract: 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.
Abstract: Questionnaires for measuring patients' feelings or beliefs are commonly used in clinical settings for diagnostic purposes, clinical decision making, or treatment evaluation. Raw scores of a patient can be evaluated by comparing them with norms based on a reference population. Using the Pain Cognition List (PCL-2003) as an example, this article shows how clinical questionnaires can be normed with multiple regression of raw scores on demographic and other patient variables. Compared with traditional norm tables for subgroups based on age or gender, this approach offers 2 advantages. First, multiple regression allows determination of which patient variables are relevant to the norming and which are not (validity). Second, by using information from the entire sample, multiple regression leads to continuous and more stable norms for any subgroup defined in terms of prognostic variables (reliability).
Abstract: 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.
Abstract: 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 (<or=3 weeks). They completed questionnaires on background variables, fear-avoidance model variables and LBP outcome (Graded Chronic Pain Scale, GCPS) at baseline, 3, 6, and 12 months follow-up and at the end of the study. Two-hundred and twenty-two acute LBP patients were included, of whom 174 provided full follow-up information (78.4%). A backward ordinal regression analysis showed previous LBP history and pain intensity to be the most important predictors of end of study GCPS. Of the fear-avoidance model variables, only negative affect added to this model. Our results do not really support the longitudinal validity of the fear-avoidance model, but they do feed the discussion on the role of pain-related fear in early stages of LBP.
Abstract: The present study sought to investigate to what extent patients with chronic low back pain and pain-free control subjects selectively attend to pain-related stimuli as measured with 2 dot-probe tasks with word stimuli and pictorial stimuli. Selective attentional processing was measured by means of 3 indices: the bias index, a congruency effect, and an incongruency effect. Pain-related fear as a trait measure (Tampa Scale for Kinesiophobia [TSK]) was expected to be positively associated with all indices of selective attentional processing of pain stimuli. Results were analyzed with repeated-measures analysis of variance. An incongruency effect was found for patients and to a significantly less degree for pain-free control subjects on the dot-probe task with pictorial stimuli, indicating that pain patients have difficulty disengaging from threat pictures. Pain-related fear as a trait measure (TSK) was not associated with selective attentional processing of word and pictorial stimuli in either pain patients or control subjects. Results from the present study are discussed, and directions for future research are provided. PERSPECTIVE: Demonstrating difficulty to disengage from threat might be clinically relevant because patients might pay less attention to fear-disconfirming information and remain engaged in avoidance, which might eventually lead to prolonged anxiety states.
Abstract: To develop a self-report measure for assessment of the stage of change in patients with osteoarthritis, in order to identify patients who would benefit from a self-management programme.
Abstract: Fear of (re)injury/movement has been identified as a potential predictor of chronic disability in complex regional pain syndrome type I (CRPS-I). In order to reduce pain-related fears and pain disability, graded exposure in vivo (GEXP) is likely to be an appropriate treatment. Indeed, there is evidence that in chronic pain patients reporting substantial fear of (re)injury/movement, GEXP is successful in reducing pain disability. However, the efficacy of exposure-based protocols in the treatment of CRPS-I patients for reducing pain disability has not been tested. The main research question of this study was whether the reduction of pain-related fear through GEXP also resulted in a decrease of disability in a subgroup of patients with CRPS-I who report substantial pain-related fear. A single-case experimental ABCD-design was used with random determination of the start of the intervention. Eight patients with CRPS-I were included in the study. To assess daily changes in pain intensity, pain-related fear, pain catastrophizing, and activity goal achievement, a diary was used. Standardized questionnaires of pain-related fear, pain disability, and self-reported signs and symptoms of CRPS-I were administered before and after each intervention, and at 6-month follow-up. The current study supports a GEXP approach to chronic CRPS-I. The GEXP was successful in decreasing levels of self-reported pain-related fear, pain intensity, disability, and physiological signs and symptoms. These results support the hypothesis that the meaning people attach to a noxious stimulus influences its experienced painfulness, and that GEXP activates cortical networks and reconciles motor output and sensory feedback.
Abstract: In the current study we report findings on the effects of experimentally induced catastrophizing about pain on expected pain, experienced pain and escape/avoidance behavior during a cold pressor task in a sample of healthy participants. It was hypothesized that increasing the level of catastrophizing would result in a higher level of expected pain, a higher level of experienced pain, and a shorter duration of ice-water immersion. Also, it was hypothesized that these relations might be stronger for participants who already catastrophized about pain prior to the experiment. The results demonstrated that despite the successful attempt to induce catastrophizing, this neither significantly affected expected pain, experienced pain, and duration of ice-water immersion, nor were these relations moderated by the pre-experimental level of catastrophizing. Although the level of catastrophizing was successfully manipulated, more similar experiments are necessary in order to give a more definite answer on the possible causal status of pain catastrophizing.
Abstract: This study investigated the effects of an exposure in vivo treatment for chronic pain patients with high levels of fear and avoidance. The fear-avoidance model offers an enticing explanation of why some back pain patients develop persistent disability, stressing the role of catastrophic interpretations; largely fueled by beliefs and expectations that activity will cause injury and will worsen the pain problem. Recently, an exposure in vivo treatment was developed that aims to enhance function by directly addressing these fears and expectations. The purpose of this study was to describe the short-term, consequent effect of an exposure in vivo treatment. The study employed a multiple baseline design with six patients who were selected based on their high levels of fear and avoidance. The results demonstrated clear decreases in rated fear and avoidance beliefs while function increased substantially. These improvements were observed even though rated pain intensity actually decreased somewhat. Thus, the results replicate and extend the findings of previous studies to a new setting, with other therapists and a new research design. These results, together with the initial studies, provide a basis for pursuing and further developing the exposure technique and to test it in group designs with larger samples.
Abstract: The aim of the present study was to examine (a) whether a cognitive-behavioral treatment (differentially) affects pain coping and cognition; and (b) whether changes in pain coping and cognition during treatment mediate treatment outcome. Participants in this randomized clinical trial were 148 patients with chronic low back pain attending a multidisciplinary treatment program consisting of operant-behavioral treatment plus cognitive coping skills training (N = 59) or group discussion (N = 58) or allocated to a waiting list control condition (N = 31). Patients improved with respect to level of depression, pain behavior and activity tolerance at posttreatment and 12-month follow-up. Treatment also resulted in a short- and long-term decrease in catastrophizing and an enhancement of internal pain control. Changes in catastrophizing and to a lesser degree in internal pain control mediated the reduction in level of depression and pain behavior following treatment. The use of behavioral and cognitive interventions aimed at decreasing catastrophizing thoughts about the consequences of pain and promoting internal expectations of pain control possibly constitute an important avenue of change irrespective of the type of treatment.
Abstract: This study investigated whether pain catastrophizing is associated with distress and perceived disability in patients with atrial fibrillation, whether pain catastrophizing predicts pain and fear during a medical procedure of atrial cardioversion, and whether pain catastrophizing influences the effects of an opioid analgesic during internal cardioversion.
Abstract: (1) To investigate the factor structure of the Tampa Scale for Kinesiophobia (TSK) in a Dutch-speaking sample of chronic low back pain (CLBP) patients using confirmatory factor analysis, (2) to examine whether the internal structure of the TSK extends to another group of fibromyalgia (FM) patients, and (3) to investigate the stability of the factor structure in both patient groups using multi-sample analysis.
Abstract: The factor structure, reliability and validity of the Health Care Providers' Pain and Impairment Relationship Scale (HC-PAIRS) were determined in the current study. Furthermore, the ability of the HC-PAIRS to serve as a predictor for work and activity recommendations of paramedical health care providers was examined.
Abstract: This study examined psychometric properties of the Pain Anxiety Symptoms Scale (PASS), a measure of pain-related fear. A recently developed shortened version of the PASS, the PASS-20, was also investigated. Previously reported factor structures of the PASS were tested by means of confirmatory factor analysis. Results indicated that all models fitted adequately but that a five-factor solution fitted slightly better compared to the other models tested. The four-factor solution of the PASS-20 was tested by means of confirmatory factor analysis and results indicated adequate fit. Moreover, the four-factor solution of the PASS-20 was invariant among fibromyalgia and low-back pain patients. Convergent validity of the original PASS and the PASS-20 was good and internal consistency reliability adequate to excellent. The suitability of the original PASS and the PASS-20 are discussed and directions for future research are provided.
Abstract: Cross-sectional associations were examined between pain catastrophizing and several health indices in 1,164 people with musculoskeletal pain from a Dutch community sample. Health indices included in the present study were specialist consultation, use of medication, and absenteeism or work disability. The results demonstrate that for people with a current episode of musculoskeletal pain, pain catastrophizing, pain intensity, and the presence of multiple pain locations were significantly associated with specialist consultation, use of pain medication, and absenteeism or work disability. The authors conclude that the role of pain itself has perhaps been underestimated in recent models of chronic pain-related disability. Some clinical implications and suggestions for further research are given.
Abstract: The present study investigated the relationships between pain-related fear, attention to pain, and pain intensity in daily life in patients with chronic low back pain. An experience sampling methodology was used in which electronic diary data were collected by means of palmtop computers from 40 chronic low back pain patients who were followed for one week. Attention to pain was hypothesized to mediate the relation between pain-related fear and pain intensity. Further, pain-related fear as a trait characteristic was expected to moderate the relation between attention to pain and pain intensity. Multi-level analysis was used for all analyses. Although the tested mediation models yielded statistically significant mediation effects, the sizes of these effects were relatively small and clinically irrelevant. Instead, results suggested that pain-related fear and attention to pain independently predicted pain intensity. No evidence for moderation of the relation between attention to pain and pain intensity by pain-related fear as a trait characteristic was found. Implications of the results from this study are discussed and suggestions for future research are provided.
Abstract: The present study investigated the influence of sensory focusing and distraction on pain tolerance and self-reported pain intensity in healthy female university students ranking high or low in pain-related fear. Pain was induced experimentally by means of a cold pressor test. Results showed that individuals high in pain-related fear groups had greater pain intensity ratings than those low in pain-related fear groups. A planned comparison analysis showed that distraction produced reduced pain ratings only in low fearful individuals, whereas sensory focusing led to reduced pain ratings only in high fearful individuals. Self-report measures of anxiety sensitivity, pain vigilance, and pain catastrophizing were positively associated with pain intensity, but, except for pain vigilance, no meaningful association was found between these measures and pain tolerance. Implications of the results and directions for future research are provided. PERSPECTIVE: In the management of chronic pain, distraction might be especially useful in low fearful individuals. Learning to focus on the sensory aspects (ie, monitoring) of the pain experience might be beneficial for high fearful individuals.
Abstract: Pregnancy-related pelvic girdle and/or low back pain is a controversial syndrome because insight in etiology and prognosis is lacking. The controversy relates to factors eliciting pain and some prognostic factors such as the interpretation of pain at the symphysis. Recent research about treatment strategies also reflects those various opinions, in fact suggesting there is professional uncertainty about the optimal approach. Currently, physiotherapists often prescribe a pain-contingent treatment regime of relative rest and avoiding several day-to-day activities. Additionally, treatment more often includes an exercise program to guide rectification of the muscle imbalance and alignment of the pelvic girdle. Effectiveness of those interventions is not proven and the majority of the studies are methodologically flawed. Investigators draw particular attention to biomedical factors but there is growing evidence that important prognostic issues such as biopsychosocial factors appear to be even more important as point of action in a treatment program.
Abstract: The present study attempted to replicate the robustness of a two-factor model of the Tampa Scale for Kinesiophobia (TSK) in chronic low back pain (CLBP) patients and fibromyalgia patients, by means of confirmatory factor analysis. Construct and predictive validity of the TSK subscales were also examined. Results clearly indicated that a two-factor model fitted best in both pain samples. These two factors were labelled somatic focus, which reflects the belief in underlying and serious medical problems, and activity avoidance, which reflects the belief that activity may result in (re)injury or increased pain. Construct validity of the TSK and its subscales was supported by moderate correlation coefficients with self-report measures of pain-related fear, pain catastrophising, and disability, predominantly in patients with CLBP. Predictive validity was supported by moderate correlation coefficients with performance on physical performance tests (i.e., lifting tasks, bicycle task) mainly in CLBP patients. Implications of the results are discussed and directions for future research are provided.
Abstract: There is growing evidence supporting the relationship between pain-related fear and functional disability in chronic musculoskeletal pain conditions. In osteoarthritis (OA) patients the role of pain-related fear and avoidance has received little research attention so far. The present study investigates the degree to which pain-related fear, measured with the Tampa Scale for Kinesiophobia (TSK), influences daily functioning in OA patients. The purpose of the present paper was twofold: (1) to investigate the factor structure of the TSK in a sample of OA patients by means of confirmatory factor analysis; and (2) to investigate the role of pain-related fear in OA compared to other factors, such as radiological findings and level of pain intensity. The results show that TSK consists of two factors, called 'activity avoidance' and 'somatic focus', which is in line with other studies in low back pain and fibromyalgia. Furthermore, pain-related fear occurred to a considerable extent in this sample of osteoarthritis patients and was negatively associated with daily functioning. Level of pain and level of pain-related fear were significantly associated with functional limitations. Radiological findings were not significant predictors and when compared to pain-related fear they were not significant. These findings underscore the importance of pain-related fear in daily functioning of OA patients. Therefore, treatment strategies aiming at reduction of pain-related fear in OA patients need to be developed and investigated.
Abstract: The present study assessed, by means of a modified Stroop paradigm, whether highly fearful patients with chronic low back pain pay selective attention to words related to movement and injury. Two groups of patients (High Fear and Low Fear) were included based on their scores on the Tampa Scale of Kinesiophobia (TSK), a measure of fear of movement or (re)injury. A control group was recruited by means of advertisement in a local newspaper. Repeated-measures analysis of variance was conducted to examine whether highly fearful pain patients pay more selective attention to movement and injury words, compared to patients with low pain-related fear and controls. The results from the present study do not support the proposition that highly fearful patients with chronic low back pain selectively pay attention to words related to injury and movement. Limitations of the modified Stroop paradigm are discussed as well as the need for the application of alternative methods such as the dot-probe paradigm.
Abstract: Patients with fibromyalgia often present with increased levels of disability and physical functioning, for which the determinants are still unclear. In patients with other musculoskeletal pain syndromes, such as chronic low back pain, physical performance and disability levels are shown to be strongly associated with pain-related fear, and even stronger than pain severity. The present study was aimed at examining the role of pain-related fear and attentional processes on tolerance for physical activity in fibromyalgia patients. High and low fearful fibromyalgia patients (N=81) were requested to perform a physical task, a cognitive (reaction time) task, and a dual task in which the physical and cognitive tasks were combined. It was hypothesized that high fearful patients would terminate the physical performance task sooner than low fearful patients, and would show a greater disruption on the cognitive task. In addition, it was expected that when distracted in the dual task, high fearful patients would show improved performance on the physical task after a fear reduction instruction. The results showed that pain itself was a greater predictor of activity tolerance than pain-related fear, but that pain-related fear was the stronger predictor of reaction times on the cognitive task. Also, all groups showed equal improvement in physical performance in the dual task. The findings suggest that baseline pain acts as an occasion setter which determines the level of physical activity the patient is willing to perform, regardless of pain increase and threat-reducing instructions.
Abstract: Given the individual and economic burden of chronic work disability in low back pain patients, there is a need for effective preventive interventions. The aim of the present study was to investigate whether problem-solving therapy had a supplemental value when added to behavioral graded activity, regarding days of sick leave and work status.
Abstract: In chronic pain patients, preoccupation with or attention to pain is associated with pain-related fear and perceived pain severity. The current study investigated psychometric properties of the pain vigilance and awareness questionnaire (PVAQ). An exploratory factor analysis on Dutch fibromyalgia patients indicated that a two-factor solution was most suitable. The first factor could be referred to as attention to pain and the second factor was interpreted as attention to changes in pain. A confirmatory factor analysis, testing three different factor structures in two independent samples (Dutch fibromyalgia patients and American pain patients with various diagnoses) showed that the goodness-of-fit indicators for all models were satisfactory. The existence of the previously reported intrusion subscale of the PVAQ as a unique construct within the PVAQ was discussed. This subscale should be further extended by non-reverse-keyed items. With regard to the convergent validity, the PVAQ was highly correlated with related constructs such as the pain catastrophizing scale (PCS), pain anxiety symptoms scale (PASS), and Tampa scale of kinesiophobia (TSK). The attention to pain subscale was significantly stronger associated with these pain-related measures than the attention to changes in pain subscale, indicating that attention to changes in pain is a distinctive construct. The uniqueness of the attention to changes in pain subscale was also supported by an exploratory factor analysis on all items of the PVAQ, PCS, PASS, and TSK which showed that all items from that scale loaded on one separate factor. Overall, the PVAQ showed good internal consistency. Implications for future research and treatment interventions are discussed.
Abstract: For years enhancement of a patient's level of physical fitness has been an important goal in rehabilitation treatment in chronic low back pain (CLBP), based on the hypothesis that physical deconditioning contributes to the chronicity of low back pain. However, whether this hypothesis in CLBP holds is not clear. In this paper, possible mechanisms that contribute to the development of physical deconditioning in CLBP, such as avoidance behaviour and suppressive behaviour, are discussed. The presence of both deconditioning-related physiological changes, such as muscle atrophy, changes in metabolism, osteoporosis and obesity as well as deconditioning related functional changes, such as a decrease in cardiovascular capacity, a decrease in muscle strength and impaired motor control in patients with CLBP are discussed. Results of studies on the level of physical activities in daily life (PAL) and the level of physical fitness in patients with CLBP compared to healthy controls were reviewed. In studies on PAL results that were either lower or comparable to healthy subjects were found. The presence of disuse (i.e., a decrease in the level of physical activities in daily life) in patients with CLBP was not confirmed. The inconclusive findings in the papers reviewed may partly be explained by different measurement methods used in research on PAL in chronic pain. The level of physical fitness of CLBP patients also appeared to be lower or comparable to the fitness level of healthy persons. A discriminating factor between fit and unfit patients with back pain may be the fact that fit persons more frequently are still employed, and as such may be involved more in physical activity. Lastly some suggestions are made for further research in the field of disuse and deconditioning in CLBP.
Abstract: The transition from acute to chronic low back pain (LBP) is influenced by many interacting factors. Pain-related fear, as measured by the Tampa Scale for Kinesiophobia (TSK) and the Fear-Avoidance Beliefs Questionnaire (FABQ), is one of these factors. The objectives of this study were to investigate, in a population with acute LBP, the reliability of TSK and FABQ through evaluation of the internal consistency, the test-retest reliability, and the concurrent validity between TSK and FABQ. One hundred and Seventy-Six patients suffering LBP for no longer than 4 weeks completed a Visual Analogue Scale for pain (VAS), the TSK, the FABQ, and a socio-demographic questionnaire. Each patient completed the VAS, TSK, and FABQ twice within 24 h. Internal consistency of TSK and FABQ scores range from alpha=0.70 to 0.83. Test-retest reliability ranges from r(s)=0.64 to 0.80 (P<0.01). Concurrent validity is moderate, ranging from r(s) =0.33 to 0.59 (P<0.01). It may be concluded that in a population with acute LBP, both the TSK and the FABQ are reliable measures of pain-related fear. In the clinical setting they may provide the practitioner a means of identifying pain-related fear in a patient with acute LBP.
Abstract: To test the assumption that fear of injury leads to disability and physical deconditioning in patients with chronic low back pain (CLBP) and to evaluate the relation between disability and physical deconditioning.
Abstract: A. Antonovsky (1987) defined the sense of coherence (SOC) as the ability to perceive a stressor as comprehensible, manageable, and meaningful. In this prospective study of pregnant women, the authors tested the relationships between the SOC in early pregnancy and crisis support and symptom severity of posttraumatic stress disorder (PTSD) and depression after pregnancy loss. A total of 1,372 women completed questionnaires in early pregnancy, including measures for the SOC and depressive symptoms, and were followed for every 2 months thereafter until 1 month after the birth due-date. Of this group, 126 women had a pregnancy loss, and 118 of them completed measures for crisis support, PTSD, and depression about 1 month later. The results showed that a stronger SOC in early pregnancy renders women somewhat resilient to symptoms of PTSD and depression after pregnancy loss, which appears to be due to the mobilization of crisis support.
Abstract: 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.
Abstract: The present study investigated selective attention and avoidance of pain-related stimuli by applying a dot-probe paradigm to healthy university students. The study consisted of 2 successive experiments. The first experiment, a direct replication of a previous study, failed to find evidence for the presence of attentional bias toward pain-related words in highly fearful individuals compared to those who were low in pain-related fear. A second experiment was set up to examine whether avoidance of pain stimuli was influenced by presentation time of word pairs and to investigate the effects of gender on processing pain-related stimuli. The results from the second experiment showed that presentation time of words, fear of pain scores, and gender in isolation or in interaction with each other did not significantly influence attention to and avoidance of pain-related stimuli. Implications of the results are discussed, and directions for future research are provided.
Abstract: In a randomized clinical trial, the effectiveness of behavioral graded activity was assessed as compared to usual care provided by physiotherapists for patients after first-time lumbar disc surgery (n = 105).
Abstract: Attitudes and beliefs, or the treatment orientation, of health care providers appear to be important in the management of non-specific chronic low back pain (CLBP). The aims of the current study were two-fold: First of all, the physiotherapists' opinion towards various aspects of the management of CLBP was surveyed. Secondly, in a principal factor analysis, it was investigated whether underlying dimensions could be identified in order to develop the Pain Attitudes and Beliefs Scale for Physiotherapists (PABS_PT). In total, 421 physiotherapists (response rate 62.3%) participated in this study. The results suggested that the majority of physiotherapists hold the opinion that CLBP is not a dangerous condition, that sport should not be discouraged and that patients should not refrain from all physical activity. Moreover physiotherapists seem to hold the opinion that the way patients view their pain influences the progress of symptoms. Finally, physiotherapists seem to hold the opinion that therapy can completely alleviate the functional symptoms and that therapy may have been successful even if pain remains. The principal factor analysis (PAF) yielded an interpretable 2-factor model. Based on highest loading items, factor 1 was labelled 'biomedical orientation', whereas factor 2 was labelled 'behavioural orientation'. The internal consistency (Cronbach's Alpha) of factor 1 was 0.84 and for factor 2, 0.54 explaining 25.2% and 8.2%, respectively, of the total variance. Assessment of the effect of the physiotherapists' characteristics on scores on the different scales was encouraging as results pointed in the directions one would expect. Physiotherapists who attended biopsychosocial education courses had statistically significantly higher scores on the 'behavioural orientation' factor and vice versa. Biomedical specialists scored statistically significantly higher on the 'biomedical orientation' factor. Furthermore, the findings suggested that the PABS_PT discriminates between physiotherapists with a 'behavioural orientation' vs those with a 'biomedical orientation'. To examine the influence of these different treatment orientations with regard to CLBP on patient outcome is a challenge for the near future.
Abstract: Behavioral approaches to treating patients following lumbar disc surgery are becoming increasingly popular. The treatment method is based on the assumption that pain and pain disability are not only influenced by somatic pathology, if found, but also by psychological and social factors. A recent study highlighted the effectiveness of cognitive-behavioral interventions, as compared to no treatment, for chronic low back patients. However, to the authors' knowledge, there is no randomized controlled trial that evaluates a behavioral program for patients following lumbar disc surgery. The purpose of this study was to assess the effectiveness of a behavioral graded activity (BGA) program compared to usual care (UC) in physiotherapy following first-time lumbar disc surgery. The BGA program was a patient-tailored intervention based upon operant therapy. The essence of the BGA is to teach patients that it is safe to increase activity levels. The study was designed as a randomized controlled trial. Assessments were carried out before and after treatment by an observer blinded to treatment allocation. Patients suffering residual symptoms restricting their activities of daily living and/or work at the 6 weeks post-surgery consultation by the neurosurgeon were included. The exclusion criteria were: complications during surgery, any relevant underlying pathology, and any contraindication to physiotherapy or the BGA program. Primary outcome measures were the patient's Global Perceived Effect and the functional status. Secondary measures were: fear of movement, viewing pain as extremely threatening, pain, severity of the main complaint, range of motion, and relapses. Physiotherapists in the BGA group received proper training. Between November 1997 and December 1999, 105 patients were randomized; 53 into the UC group and 52 into the BGA group. The unadjusted analysis shows a 19.3% (95% CI: 0.1 to 38.5) statistically significant difference to the advantage of the UC group on Global Perceived Effect. This result, however, is not robust, as the adjusted analyses reveal a difference of 15.7% (95% CI: -3.9 to 35.2), which is not statistically significant. For all other outcome measures there were no statistically significant or clinically relevant differences between the two intervention groups. In general, the physiotherapists' compliance with the BGA program was satisfactory, although not all treatments, either in the BGA or the UC group, were delivered exactly as planned, resulting in less contrast between the two interventions than had been planned for. There was one re-operation in each group. The BGA program was not more effective than UC in patients following first-time lumbar disc surgery. For Global Perceived Effect there was a borderline statistically significant difference to the advantage of the UC group. On functional status and all other outcome measures there were no relevant differences between interventions. The number of re-operations was negligible, indicating that it is safe to exercise after first-time disc surgery.
Abstract: The aim of the present study was to examine the association between pain catastrophizing and general health status in a Dutch adult community sample, including various subgroups of people with musculoskeletal pain in the analyses. For exploratory reasons this study partly replicated previous studies of the factor structure, reliability, and validity of the Pain Catastrophizing Scale (PCS). Results demonstrated that across different pain subgroups, catastrophizing uniquely contributed variance to the prediction of the various aspects of general health status beyond the variance explained by pain intensity, age, gender, and chronicity. Across subgroups strongest associations were found between catastrophizing and mental health, general health perception, social functioning, and vitality. Furthermore, the association between catastrophizing and the various aspects of general health status was not moderated by the chronicity of the pain. Results of the confirmatory factor analysis statistically confirmed a three-factor model of the PCS, which was invariant across different subgroups of people with musculoskeletal pain. Inter-factor correlations were high, and the incremental explanatory power of the three-factor model over that of a one-factor model was only marginal. This implies that a one-factor model might be justifiable as well, at least in the general community. Across various pain subgroups the reliability of the PCS total and subscales was adequate. Additional evidence for the concurrent validity of the PCS was found as well.
Abstract: Although the modified Stroop paradigm is considered to be a prominent paradigm for investigating selective attention in emotional disorders, relatively few studies have applied this paradigm to examine selective attention in chronic pain patients. Moreover, the results from these studies are not robust. The purpose of this article is to review the evidence for attentional bias in chronic pain patients, by means of a meta-analysis. Data from five studies were pooled and summarized into a mean difference (MD). Significant MD estimations (in milliseconds) were found for both sensory pain words (MD=26.7; 95% confidence interval (CI) 10.0-42.9) and affective pain words (MD=28.1; 95% CI 0.4-55.8). Meta-regression analysis indicated that methodological quality did not significantly affect the pooled MD estimation for both sensory pain words and affective pain words. Thus, the results from the present meta-analysis on studies applying the modified Stroop paradigm suggest that chronic pain patients selectively attend to both pain sensory and pain affective stimuli. Furthermore, the MD estimation did not depend on the methodological quality, tentatively indicating that even though studies differed in methodology, the results were rather consistent. Implications of the results are discussed.
Abstract: The current study examined validity and reliability of the Pain Vigilance and Awareness Questionnaire (PVAQ) in two samples of healthy college students. Exploratory and confirmatory factor analysis showed that a two-factor model of the PVAQ was most suitable in the present study. The first factor could be referred to as attention to pain whereas the second factor could be specified as attention to changes in pain. With regard to the convergent and divergent validity, the PVAQ was found to correlate highly with related constructs like catastrophising (PCS) and general body vigilance (BVQ). The correlation between PVAQ and pain-related fear (FPQ) was moderate, whereas correlations with unrelated constructs like trait anxiety (STAI-T) and fear of spiders (FSQ) were low. Furthermore, the PVAQ showed good internal consistency and fair test-retest reliability. Altogether, these findings suggest that the PVAQ is a valid and reliable measure of pain vigilance in healthy individuals. The results of this study can be regarded as a starting point for further validation of the PVAQ in clinical pain populations. Implications for future research and treatment interventions are discussed.
Abstract: By using a population-based cohort of the general Dutch population, the authors studied whether an excessively negative orientation toward pain (pain catastrophizing) and fear of movement/(re)injury (kinesiophobia) are important in the etiology of chronic low back pain and associated disability, as clinical studies have suggested. A total of 1,845 of the 2,338 inhabitants (without severe disease) aged 25-64 years who participated in a 1998 population-based questionnaire survey on musculoskeletal pain were sent a second questionnaire after 6 months; 1,571 (85 percent) participated. For subjects with low back pain at baseline, a high level of pain catastrophizing predicted low back pain at follow-up (odds ratio (OR) = 1.7, 95% confidence interval (CI): 1.0, 2.8) and chronic low back pain (OR = 1.7, 95% CI: 1.0, 2.3), in particular severe low back pain (OR = 3.0, 95% CI: 1.7, 5.2) and low back pain with disability (OR = 3.0, 95% CI: 1.7, 5.4). A high level of kinesiophobia showed similar associations. The significant associations remained after adjustment for pain duration, pain severity, or disability at baseline. For those without low back pain at baseline, a high level of pain catastrophizing or kinesiophobia predicted low back pain with disability during follow-up. These cognitive and emotional factors should be considered when prevention programs are developed for chronic low back pain and related disability.
Abstract: Whether the effects of exposure to 1 movement generalize to another dissimilar movement was investigated in 37 patients with low back pain (15 men, 22 women). Two movements were executed twice: bending forward while standing and lifting 1 leg while lying down. During each trial, baseline pain, expected pain, and experienced pain were recorded. Similar ratings for perceived harm were obtained. Analyses revealed an initial over prediction of pain, but after exposure the overprediction was readily corrected. This exposure effect did not generalize toward another dissimilar movement. These results were only characteristic for patients with catastrophic thinking about pain. Low pain catastrophizers did not overpredict pain. There were no effects of exposure on perceived harm. Exposure may profitably be conceived of as the learning of exceptions to a general rule.
Abstract: Although cognitive-behavioural treatments of patients with chronic pain generally are reported to be effective, customization might increase their effectiveness. One possible way to customize treatment is to focus the intervention on the supposed mechanism underlying the transition from acute to chronic pain disability. Evidence is accumulating in support of the conjecture that pain-related fear and associated avoidance behaviours are crucial in the development and maintenance of chronic pain disability. It seems timely to apply this knowledge to the cognitive-behavioural management of chronic pain. Two studies are presented here. Study 1 concerns a secondary analysis of data gathered in a clinical trial that was aimed at the examination of the supplementary value of coping skills training when added to an operant-behavioural treatment in patients with chronic back pain. The results show that, compared with a waiting list control, an operant-behavioural treatment with or without pain-coping skills training produced very modest and clinically negligible decreases in pain-related fear. Study 2 presents the effects of more systematic exposure in vivo treatment with behavioural experiments in two single patients reporting substantial pain-related fear. Randomization tests for AB designs revealed dramatic changes in pain-related fear and pain catastrophizing. In both cases, pain intensity also decreased significantly, but at a slower pace. Differences before and after treatment revealed clinically significant improvements in pain vigilance and pain disability.
Abstract: The purpose of this study was to survey the level of fear-avoidance beliefs for practicing general practitioners and physical therapists and to relate this to self-reported practice behaviors for patients with back pain. To this end, 60 general practitioners and 71 physical therapists were recruited. These participants completed a questionnaire including 11 items slightly revised from instruments designed to assess fear-avoidance beliefs in patients, and four items about treatment practices. The results indicated that these health care practitioners on the average generally held beliefs that are consistent with the current evidence, but there were also indications that some practitioners held beliefs reflecting fear-avoidance. More than two-thirds reported that they would advise a patient to avoid painful movements, more than one-third believed a reduction in pain is a prerequisite for return-to-work, while more than 25% reported that they believe sick leave is a good treatment for back pain. These beliefs were found to be related to reported practice behavior. Those with high levels of fear-avoidance beliefs were compared to those with low levels. Those with high levels of fear-avoidance belief had an increased risk for believing sick leave to be a good treatment (RR = 2.0; 90%CI = 1.02-3.92), not providing good information about activities (RR = 1.7; 90%CI = 1.19-2.45), and being uncertain about identifying patients at risk for developing persistent pain problems (RR = 1.5; 90%CI = 1.00-2.27). It is concluded that some practitioners hold beliefs reflecting fear-avoidance and that these beliefs may influence treatment practice.
