Ivan P.J. Huijnen

Do depression and pain intensity interfere with physical activity in daily life in patients with Chronic Low Back Pain

&NA; Patients with chronic pain may have difficulties estimating their own physical activity level in daily life. Pain‐related factors such as depression and pain intensity may affect a patients’ ability to estimate their own daily life activity level. This study evaluates whether patients with Chronic Low Back Pain (CLBP) who are more depressed and/or report more pain indeed have a lower objectively assessed daily life activity level or whether they only perceive their activity level as lower. Patients with CLBP were included in a cross‐sectional study. During 14 days physical activity in daily life was measured, with both an electronic diary and an accelerometer. Multilevel analyses were performed to evaluate whether a higher level of depression and/or pain intensity was associated with a lower objectively assessed activity level or the discrepancy between the self‐reported and objectively assessed daily life activity levels. Results, based on 66 patients with CLBP (mean RDQ score 11.8), showed that the objectively assessed daily life activity level is not associated with depression or pain intensity. There was a moderate association between the self‐reported and objectively assessed activity levels (&bgr; = 0.39, p < 0.01). The discrepancy between the two was significantly and negatively related to depression (&bgr; = −0.19, p = 0.01), indicating that patients who had higher levels of depression judged their own activity level to be relatively low compared to their objectively assessed activity level. Pain intensity was not associated with the perception of a patients activity level (&bgr; = 0.12, ns).

Are older adults with chronic musculoskeletal pain less active than older adults without pain? A systematic review and meta-analysis.

OBJECTIVE To compare the overall levels of physical activity of older adults with chronic musculoskeletal pain and asymptomatic controls. REVIEW METHODS A systematic review of the literature was conducted using a Cochrane methodology and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Major electronic databases were searched from inception until December 2012, including the Cochrane Library, CINAHL, EBSCO, EMBASE, Medline, PubMed, PsycINFO, and the international prospective register of systematic reviews. In addition, citation chasing was undertaken, and key authors were contacted. Eligibility criteria were established around participants used and outcome measures focusing on daily physical activity. A meta-analysis was conducted on appropriate studies. RESULTS Eight studies met the eligibility criteria, four of these reported a statistically lower level of physical activity in the older adult sampl e with chronic pain compared with the asymptomatic group. It was possible to perform a non-heterogeneous meta-analysis on five studies. This established that 1,159 older adults with chronic pain had a significantly lower level of physical activity (-0.20, confidence interval 95% = -0.34 to -0.06, p = 0.004) compared with 576 without chronic pain. CONCLUSION Older adults with chronic pain appear to be less active than asymptomatic controls. Although this difference was small, it is likely to be clinically meaningful. It is imperative that clinicians encourage older people with chronic pain to remain active as physical activity is a central non-pharmacological strategy in the management of chronic pain and is integral for healthy aging. Future research should prioritize the use of objective measurement of physical activity.

Assessment of physical activity in daily life in patients with musculoskeletal pain

Patients with musculoskeletal pain often report limitations in daily functioning due to pain. Recently, the World Health Organisation (WHO) recommended in their International Classification of Functioning, Disability and Health (ICF) to accentuate patients remaining possibilities in functioning instead of focussing on restrictions. In patients with musculoskeletal pain, this would imply that a persons “daily activity level” rather than his/her “disability level” has to be focussed upon. At this moment, broad consensus about how to measure physical activity in daily life in patients with pain has not been established. The objectives of this study were twofold, firstly to identify instruments assessing the level of physical activity in daily life in patients with musculoskeletal pain and secondly to review psychometric properties of the instruments identified. In all, 42 articles derived from the literature on musculoskeletal pain were included in the review. Thirty four assessment instruments for physical activity were identified; fourteen questionnaires, ten diaries and ten instruments based on movement registration. Only, 10 out of these 34 instruments contained full or partial information regarding pain specific psychometric properties. At this moment, for quantitative assessment of physical activity, movement registration seems to be favoured based on its higher degree of objectivity in comparison with self report. Taken together more research is needed to evaluate psychometric properties of instruments measuring physical activity in musculoskeletal pain.

Differences in activity-related behaviour among patients with chronic low back pain

The aim of the present study was to compare the subjectively reported and objectively assessed activity‐related characteristics of patients with Chronic Low Back Pain (CLBP) who were classified according to their scores on the Patterns of Activity Measure‐Pain (POAM‐P) into avoiders, persisters, mixed performers (i.e. high scores on both avoidance and persistence behaviour) or functional performers (i.e. low scores on avoidance and persistence behaviour).The aim of the present study was to compare the subjectively reported and objectively assessed activity-related characteristics of patients with Chronic Low Back Pain (CLBP) who were classified according to their scores on the Patterns of Activity Measure-Pain (POAM-P) into avoiders, persisters, mixed performers (i.e. high scores on both avoidance and persistence behaviour) or functional performers (i.e. low scores on avoidance and persistence behaviour). Patients carried an electronic diary during 14 days to assess the self-reported activity and pain intensity levels in daily life. An accelerometer was used to objectively assess their activity level during the same time period. Results were available for 79 patients. Avoiders, persisters and mixed performers showed a higher level of self-reported disability than functional performers. Avoiders were characterized by a low level of self-reported habitual activities and persisters by long objectively measured daily uptime. The objectively assessed level of physical activity did not differ between the four groups. A further analysis tested the association between pain intensity levels and self-reported and objectively assessed daily life activity levels in avoiders and persisters. In persisters, a higher level of self-reported activities in daily life was related to increased pain. The objectively assessed activity level was not associated with pain intensity.

Activity Patterns in Chronic Pain: Underlying Dimensions and Associations With Disability and Depressed Mood

UNLABELLED Activity patterns are believed to play an important role in the development and perpetuation of chronic pain. So far, 3 important activity patterns have been studied: avoidance behavior, persistence behavior, and pacing behavior. Yet, empirical evidence is limited and inconclusive about the relationships between these activity patterns and important outcomes. Therefore, the present study was aimed at identifying activity patterns by means of factor analyses and determining their relationship with disability and depressive symptomatology in participants with chronic pain (N = 132). Items across different measurement instruments pertaining to 1 particular activity pattern were aggregated, and submitted to factor analysis. Results from 3 separate factor analyses revealed 6 distinct activity patterns: pain avoidance, activity avoidance, task-contingent persistence, excessive persistence, pain-contingent persistence, and pacing. In line with our hypotheses, pain and activity avoidance, and excessive persistence, were related to higher levels of disability and depressive symptomatology. In contrast to hypotheses, pacing was associated with worse outcomes as well. Interestingly, task-contingent persistence was related to lower levels of disability and depressive symptomatology. When controlling for pain and the other activity patterns, excessive persistence and activity avoidance were the most detrimental in terms of relations with depressed mood or disability. Task-contingent persistence appeared to be the least detrimental. PERSPECTIVE Our findings suggest the existence of several activity patterns, which are differentially related to disability and depressive symptomatology, in participants with chronic pain. The present results are discussed in the light of previous findings, and may provide a new impetus for future studies on activity patterns in chronic pain research.

The disabling role of fluctuations in physical activity in patients with chronic low back pain

Patients with chronic low back pain (CLBP) often report a disabling decrease in their activity level due to pain. The nature of the association between disability, activity, and pain over time is however, unclear. An intriguing issue here is whether a high level of pain‐related disability is associated with a low activity level or are changes in the level of activity over time pain provoking and thus more disabling? The objectives of this study were to investigate associations between disability, pain intensity, pain‐related fear, and characteristics of physical activity in patients with CLBP. A total of 42 patients with CLBP were recruited from the Pain Clinic of the Maastricht University Hospital. Each pain patient carried an electronic diary for one week, in which questions about current pain intensity, and the level of physical activity were completed at 8 moments a day. Disability was scored by the Quebec Back Pain Disability Scale (QBPDS), Fear of movement by the Tampa Scale for Kinesiophobia (TSK). To explain the level of disability regression analyses were performed with disability as dependent variable and pain intensity, pain‐related fear, and consecutively the level of physical activity in daily life and fluctuations in physical activity as independent variables. Results, based on 34 patients, showed that activity fluctuations (β = 0.373, p < 0.05) rather than the mean activity level over time (β = −0.052, ns) contributed significantly in explaining disability. The results are discussed in the light of current theories, previous research, and clinical implications.

Being in pain: the role of self-discrepancies in the emotional experience and activity patterns of patients with chronic low back pain

&NA; 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.

Relationship between different measures of pain-related fear and physical capacity of the spine in patients with chronic low back pain

BACKGROUND CONTEXT It has been controversially stated that pain-related fear is a more important determining factor for disability in chronic low back pain (CLBP) than pain or physical impairment in itself. So far, the relationship between psychological and physiological determinants of chronic pain, that is, pain-related fear and physiological abilities, remains unclear. PURPOSE To evaluate whether pain-related fear assessed by different tools (both task specific and non task specific) is related to physical capacity measured by specific spine tests and, secondarily, to explore the relationship between different pain-related fear assessment tools. STUDY DESIGN/SETTING Cross-sectional study. PATIENT SAMPLE Fifty patients with CLBP (50% women; meanage [standard deviationage]: 44.2 [9.5 years]). OUTCOME MEASURES Physical capacity by means of three specific spine tests, that is, the finger-floor distance test (flexibility), a maximal isometric strength test of trunk extensor muscles (strength), and the Sorensen test (endurance). Pain-related fear by means of self-report measures, that is, the Tampa Scale for Kinesiophobia (TSK), the Photograph Series of Daily Activities (PHODA), and a fear visual analog scale (FVAS) tailored to the spine tests. METHODS Participants were asked to complete the TSK and PHODA and to perform the three spine tests. Right before performing each of the spine tests, an FVAS was filled out. Linear regression analyses controlling for gender and age were performed to study the association between the pain-related fear measurements and the results of the spine tests. To investigate the relationship between the pain-related fear measurements, correlation tests were performed. RESULTS The linear regression analyses revealed that neither the TSK and PHODA scores nor the FVAS scores were significantly related to the physical capacity measurements. The correlational tests showed no significant correlation between the PHODA, TSK, and FVAS scores. CONCLUSIONS The present study shows that neither the task-specific tool (FVAS) nor the non task-specific questionnaires (TSK and PHODA) were significantly correlated to the spine tests in patients with CLBP. This is contrary to earlier evidence according to which physical capacity is inversely related to the level of pain-related fear, and it suggests that one should not draw conclusions about physical capacity based on pain-related fear scores. Furthermore, the different assessment tools for pain-related fear were surprisingly not correlated with each other.

Effects of self-discrepancies on activity-related behaviour: explaining disability and quality of life in patients with chronic low back pain.

Summary The self‐discrepancy model is applied to chronic low back pain to explain persistence and avoidance behaviour. Whether both styles are related to disability and quality of life is evaluated. ABSTRACT In chronic low back pain (CLBP) research, the self‐discrepancy model has been applied to explain dysfunctional avoidance and persistence behaviour. The main aim of this study was to evaluate whether specific self‐discrepancies in patients with CLBP are associated with the abovementioned types of activity‐related behaviour and whether changes in self‐discrepancies over time are associated with changes in activity‐related behaviour. Furthermore, the aim was to evaluate whether avoidance and persistence behaviour are associated with a higher level of disability and a diminished quality of life and whether changes over time in avoidance and persistence behaviour result in changes in disability and quality of life. A longitudinal cohort study in a sample of patients with CLBP (N = 116), in which self‐discrepancies, disability, quality of life, and objectively registered characteristics of activity‐related behaviour were measured, was performed to evaluate the pathways in the aforementioned self‐discrepancy model. Results indicate that patients with CLBP who feel closer to their ideal‐other show more characteristics of persistence behaviour. Patients who move further away from their ideal‐own also show more characteristics of persistence behaviour. Furthermore, in patients characterized as avoider, a decrease in a patient’s daily uptime was associated with a decrease of mental health‐related quality of life.

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.