Adina C. Rusu

Fear-avoidance- and endurance-related responses to pain: Development and validation of the Avoidance-Endurance Questionnaire (AEQ)

Aim of investigation: Recent research indicated wide variability regarding pain‐related cognitive/affective and behavioral responses to pain, showing that fear‐avoidance responses (FAR) and endurance‐responses (ER) play a prominent role in the maintenance of low back pain (LBP). Until now, there is a lack of reliable and valid instruments covering FAR and ER.

Multidimensional Pain Inventory derived classifications of chronic pain : Evidence for maladaptive pain-related coping within the dysfunctional group

&NA; This study examines maladaptive pain‐related fear‐avoidance and endurance coping in subgroups of patients with chronic back pain. Hypotheses were derived from the avoidance‐endurance model of pain [Hasenbring M. Attentional control of pain and the process of chronification. In: Sandkühler J, Bromm B, Gebhart GF, editors. Progress in pain research, vol. 129. New York: Elsevier; 2000. p. 525–34.], which assumes that endurance coping (cognitive, behavioral tendency to endure severe pain to finish current activities irrespective of pain increases) leads to overuse of muscles, joints, and discs with an increase of pain as long‐term consequence. Participants were 120 patients referred for treatment of chronic pain to General Practices. They were classified as ‘dysfunctional‐DYS’ (15.8%), ‘interpersonally distressed‐ID’ (10.8%), and ‘adaptive copers‐AC’ (61.7%) based on the Multidimensional Pain Inventory [Kerns RD, Turk DC, Rudy TE. The West Haven‐Yale Multidimensional Pain Inventory (WHYMPI). Pain 1985;23:345–56.] and compared on measures of pain‐related fear‐avoidance coping (anxiety/depression; help‐/hopelessness; catastrophizing; avoidance of social/physical activity) and endurance coping (positive mood; thought suppression; endurance behavior) using the Kiel Pain Inventory [Hasenbring M. The Kiel Pain Inventory‐Manual. Three questionnaire scales for assessment of pain‐related cognitions, emotions and copying strategies. Bern:Huber; 1994.]. Multivariate analysis of variance indicated that groups differed significantly for pain‐related fear‐avoidance and endurance coping, even after control for pain intensity and depression. Univariate effects revealed that patients classified as DYS reported more anxiety/depression, help‐/hopelessness, and catastrophizing than did those classified as AC. Furthermore, the DYS group showed more thought suppression compared to AC; however, subgroups did not differ significantly with regard to avoidance of social and physical activity, and endurance behavior. Further, DYS as well as ID group showed more non‐verbal pain behavior compared to AC, which refers to the special role of operant conditioning. Implications are considered for further investigation of endurance coping to provide a more comprehensive assessment and treatment for subgroups of chronic pain patients.

The relationship between pain, disability, quality of life and cognitive-behavioural factors in chronic back pain

Purpose: This pilot study systematically examined the correlations between the outcome variables pain intensity, disability and health-related quality of life (HRQOL) and between these outcomes and known psychological risk factors for chronic low back pain (CLBP), such as depression, trait anxiety, avoidance- and endurance-related pain responses at two different assessment points. Method: Data from 52 CLBP inpatients treated in an orthopedic clinic were investigated at two points in time: during the first days after admission and 6 months after the termination of the inpatient treatment. Bivariate relationships between pain intensity, disability, HRQOL and psychological variables were examined with the help of Pearson product moment correlations. Furthermore, the differences that exist between correlations at baseline and follow-up were tested for significance. Results: Significant and large differences were found between the correlations with low correlations at baseline and high correlations at the follow-up. Furthermore, HRQOL showed a positive correlation with endurance-related and a negative correlation with avoidance-related pain responses. Conclusions: Focusing on a systematic comparison of two significant assessment time points in CLBP with an acute exacerbation at baseline, the results of this study underlined the recurrent course of LBP. The results highlight that the assessment time points play an important role in CLBP. Implications for Rehabilitation Low back pain is a major public health problem with high direct and indirect back-pain-related costs. Chronic low back pain is a disabling disease which restricts quality of life. Psychological factors may have a larger impact on disability and quality of life than pain itself. The recurrent course of low back pain highlights the importance of multidisciplinary pain management even during acute exacerbations of pain.

Fear of movement/(Re)injury in low back pain: confirmatory validation of a German version of the Tampa Scale for Kinesiophobia.

BackgroundThe Tampa Scale for Kinesiophobia (TSK), an instrument for measuring fear of movement/(re)injury, has been confirmed as an important predictor for the persistence of pain-related disability. The aims of this study were to evaluate the psychometric properties of a German version of the TSK (TSK-GV), examining aspects of content validity with special focus on fear-avoidance and endurance, and to confirm criterion-related validity in patients with low back pain (LBP).MethodsA total of 191 patients with LBP were included in this study. Several models with different factor structures from published studies were compared in a confirmatory factor analysis. Internal consistencies of the TSK-GV and its subscales were examined, and correlations with related self-report measures were calculated.ResultsThe internal consistency of the TSK-GV was α = 0.73. A two-factor model with 11 items was found to be the best fit for our data. The two factors were labelled Somatic Focus (SF) and Activity Avoidance (AA). The total score, SF and AA revealed moderate to high correlations with other fear-avoidance variables.ConclusionsThe TSK-GV is a reliable and valid measure for assessing the fear of movement/(re)injury.

Depressed pain patients differ from other depressed groups: Examination of cognitive content in a sentence completion task

Summary In contrast to depressed groups without pain, participants with pain and depression exhibit a cognitive bias specific to negative aspect of health on a sentence completion task. Abstract Depression is a common feature of chronic pain, but there is limited research into the content and frequency of depressed cognitions in pain patients. A limitation of previous research is the failure to include nonpain depressed comparison groups. The present study used a sentence completion task to investigate the content of cognition in 4 groups of participants: with pain and concurrent depression, pain without depression, depression without pain, and with neither pain nor depression. One hundred seventy‐two participants generated sentences to a set of predefined stems. Complete responses were coded by affective valence (negative, positive, and neutral) and health‐related content. As predicted, participants with depression (with and without pain) produced more negative responses than nondepressed participants (with and without pain); participants with pain (depressed and nondepressed) produced more health responses than those without pain (depressed and controls); participants with depression and pain produced more negative health responses than any other group. The strengths of the current study are the inclusion of the depressed nonpain group, the use of a comprehensive coding scheme applied by 2 independent raters, and the presence of depression validated through a diagnostic interview. In contrast to depressed groups without pain, participants with pain and depression exhibit a cognitive bias specific to negative aspect of health. This focus facilitates understanding of the relationship between depression and pain processing: The implications for therapeutic interventions are discussed.

Responsiveness and construct validity of the depression, anxiety, and positive outlook scale (DAPOS).

BackgroundThe Depression, Anxiety, and Positive Outlook Scale (DAPOS) was designed to measure mood in pain populations without contamination from somatic items. AimsThe current study examined responsiveness, internal consistency, and construct validity in pain patients. MethodA questionnaire survey before and after a multidisciplinary rehabilitation intervention was completed by chronic pain patients, the majority of whom had back pain. ResultsThe DAPOS showed excellent internal consistency (N=222, Cronbach α=0.86 for the Depression subscale, 0.90 for the Anxiety subscale, and 0.74 for the Positive Outlook subscale) and construct validity (N=82) in comparison with a variety of measures (SF-36; Pain Catastrophizing Scale; Zung Depression). Responsiveness was acceptable (ranging between 0.5 and 0.7, for both the mean change in score after treatment to the variability in patients at baseline, and the standardized response mean), although considerably lower than the Zung Depression Inventory. However, reanalysis without somatic items rendered the responsiveness of the Zung inadequate, indicating that change on this measure was due almost entirely to change in somatic symptoms without change in mood. ConclusionsResponsiveness of the DAPOS should be reassessed in treatment targeting mood change explicitly. The DAPOS scales show acceptable clinimetric and psychometric properties, and add a measurement of positive outlook to create a more balanced indication of mood in pain patients.

Subgrouping of Low Back Pain Patients for Targeting Treatments Evidence from Genetic, Psychological, and Activity-related Behavioral Approaches

Introduction:Many patients with low back pain (LBP) are treated in a similar manner as if they were a homogenous group. However, scientific evidence is available that pain is a complex perceptual experience influenced by a wide range of genetic, psychological, and activity-related factors. The leading question for clinical practice should be what works for whom. Objectives:The main aim of the present review is to discuss the current state of evidence of subgrouping based on genetic, psychosocial, and activity-related factors in order to understand their contribution to individual differences. Results:Based on these perspectives, it is important to identify patients based on their specific characteristics. For genetics, very promising results are available from other chronic musculoskeletal pain conditions. However, more research is warranted in LBP. With regard to subgroups based on psychosocial factors, the results underpin the importance of matching patients’ characteristics to treatment. Combining this psychosocial profile with the activity-related behavioral style may be of added value in tailoring the patient’s treatment to his/her specific needs. Conclusions:For future research and treatment it might be challenging to develop theoretical frameworks combining different subgrouping classifications. On the basis of this framework, tailoring treatments more specifically to the patient needs may result in improvements in treatment programs for patients with LBP.

835 FEAR OF MOVEMENT/(RE)INJURY IN CHRONIC PAIN: PRELIMINARY VALIDATION OF A GERMAN VERSION OF THE TAMPA SCALE FOR KINESIOPHOBIA

Background and Aims: The Tampa Scale for Kinesiophobia (TSK), a measure for fear of movement/(re)injury, has been confirmed as an important predictor for the persistence of pain and disability. The aims of this study were to evaluate the psychometric properties of a German version of the TSK, to examine the use of the inverse items, and to confirm the role of kinesiophobia as a predictor of disability. Methods: 191 patients with chronic low back pain were recruited. The factor structure was assessed using a Principal Components Analysis. Internal consistencies of the TSK and its subscales were examined and correlations with related self-report measures were calculated. Multiple regression analyses examined the role of the TSK as a predictor of pain-related disability. Results: Internal consistency of the TSK was a =0.74. A three-factor solution was found to account for 42.82% of the variance. The TSK explained unique disability variance, even when the influence of age, gender, pain intensity and pain duration was statistically removed. Conclusions: The German version of the TSK has been shown to be a reliable and valid measure for the assessment of fear of movement/(re)injury. In contrast to most of the previous research, the inverse items were not eliminated, but interpreted as a third factor. Importantly, the role of kinesiophobia as a significant predictor of pain-related disability was confirmed.

Comment on: chronic pain: avoidance or endurance? by Petra Karsdorp and Johan Vlaeyen.

We would like to thank Petra Karsdorp and Johan Vlaeyen for their interest and valuable comments (Karsdorp and Vlaeyen, 2009) to our paper published in this issue (Hasenbring et al., 2009), as well as for their appreciation of the avoidance-endurance model (AEM) of pain. However, we would like to note that the aim of the current paper was to report data regarding the development and validation of a new questionnaire, based on AEM hypotheses, and not to outline the AEM itself. A first comprehensive outline, focusing on the theoretical aspects of the AEM will be published shortly (Hasenbring and Verbunt, in press). A number of previous publications (Hasenbring, 2000; Hasenbring et al., 2001, 2006, 2009; Hallner and Hasenbring, 2004; Rusu and Hasenbring, 2008) have emphasized some basic assumptions of the AEM: first, it is assumed that FARand ER-related responses are linked by loose relations, with the consequence that opposite responses (e.g. fear and thought suppression) can be activated independently. Second, single affective, cognitive and behavioral responses are represented within specific response pattern. If researchers and clinicians want to make assumptions concerning the relevance of ‘‘fear-avoidance” or ‘‘endurance” responses, they need to differentiate between single responses on the one hand and specific response pattern on the other. Further, we should cautiously consider whether cognitions (e.g. thought suppression) or behavior (e.g. task persistence behavior) are described. Specifically, when single responses are investigated with respect to their relevance for pain and disability, we should be cautious in interpreting data from cross-sectional correlation designs that are not able to control for time-lags between independent and dependant variables. Keeping these preliminary reflections in mind, we would like to comment on the editorial by Karsdorp and Vlaeyen. Firstly, the authors point out that two subgroups can be classified by the AEM. This is a misunderstanding leading to some puzzling and false interpretations of AEM-derived hypotheses. For example, Karsdorp and Vlaeyen refer to only one endurance subgroup. In Hasenbring (2000), four subgroups of pain patients were described: one subgroup showing an adaptive response pattern and three subgroups revealing maladaptive patterns. Beside FAR, two endurance-related patterns were differed. One ER pattern was related with responses of high thought suppression, increased depression and high persistence behavior, while a second ER subgroup responded with task persistence behavior linked with marked positive mood despite pain. In a recent publication (Hasenbring and Verbunt, in press), these patterns are labeled as distress ER and eustress ER. We suppose that our paper on activity behavior (Hasenbring et al., 2006) was a possible origin of Karsdorp’s misunderstanding. Due to a low sample size in this study, a combined group representing endurance responses on the cognitive (thought

Chronic pain patients' perceptions of their future: a verbal fluency task

Abstract Depression is a common feature of chronic pain, but the content of depressed cognitions in groups with chronic pain may be qualitatively different from other depressed groups. Future thinking has been extensively studied in depressed population; however, to our knowledge, this is the first study to investigate future thinking, using a verbal fluency task, in chronic pain. This study investigated the content of cognitions about the future, which are postulated to be a key mechanism in the development of clinical depression, but have not been studied in groups with chronic pain. This study used the future thinking task to investigate general future thinking and health-related future thinking in 4 groups of participants: those with pain and concurrent depression, those with pain without depression, those with depression without pain, and healthy control participants. One hundred seventy-two participants generated positive and negative future events, and rated the valence and likelihood of these events. Responses were coded for health-related content by 2 independent raters. Participants with depression (with and without pain) produced more negative and less positive future events than control participants. Participants with pain (depressed and nondepressed) produced more positive health-related future events than control participants. Participants with depression and pain produced more negative health-related future events than the nondepressed pain group. The findings suggest that participants with pain and depression exhibit a cognitive bias specific to negative aspects of health-related future thinking. This focus facilitates understanding of the relationship between depression and pain processing. The implications for therapeutic interventions are discussed.