Johan W.S. Vlaeyen

Fear of movement/( re) injury in chronic low back pain and its relation to behavioral performance

&NA; Two studies are presented that investigated ‘fear of movement/(re)injury’ in chronic musculoskeletal pain and its relation to behavioral performance. The 1st study examines the relation among fear of movement/(re)injury (as measured with the Dutch version of the Tampa Scale for Kinesiophobia (TSK‐DV)) (Kori et al. 1990), biographical variables (age, pain duration, gender, use of supportive equipment, compensation status), pain‐related variables (pain intensity, pain cognitions, pain coping) and affective distress (fear and depression) in a group of 103 chronic low back pain (CLBP) patients. In the 2nd study, motoric, psychophysiologic and self‐report measures of fear are taken from 33 CLBP patients who are exposed to a single and relatively simple movement. Generally, findings demonstrated that the fear of movement/(re)injury is related to gender and compensation status, and more closely to measures of catastrophizing and depression, but in a much lesser degree to pain coping and pain intensity. Furthermore, subjects who report a high degree of fear of movement/(re)injury show more fear and escape / avoidance when exposed to a simple movement. The discussion focuses on the clinical relevance of the construct of fear of movement/(re)injury and research questions that remain to be answered.

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

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

The role of fear of movement/(re)injury in pain disability

It is now well established that in chronic low back pain, there is no direct relationship between impairments, pain, and disability. From a cognitive-behavioral perspective, pain disability is not only influenced by the organic pathology, but also by cognitive-perceptual, psychophysiological, and motoric-environmental factors. This paper focuses on the role of specific beliefs that are associated with avoidance of activities. These beliefs are related to fear of movement and physical activity, which is (wrongfully) assumed to cause (re)injury. Two studies are presented, of which the first examines the factor structure of the Tampa Scale for Kinesiophobia (TSK), a recently developed questionnaire that is aimed at quantifying fear of movement/(re)injury. In the second study, the value of fear of movement/(re)injury in predicting disability levels is analyzed, when the biomedical status of the patient and current pain intensity levels are controlled for. In addition, the determinants of fear of movement/(re)injury are examined. The discussion focuses on the clinical relevance of the fear-avoidance model in relation to risk assessment, assessment of functional capacity, and secondary prevention.

Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment.

ObjectiveThe aim of the current study was to examine the relation between catastrophizing and pain intensity, pain-related disability, and psychological distress in a group of patients with chronic pain, controlling for the level of physical impairment. Furthermore, it was examined whether these relations are the same for three subgroups of chronic pain patients: those with chronic low back pain, those with chronic musculoskeletal pain other than low back pain, and those with miscellaneous chronic pain complaints, low back pain and musculoskeletal pain excluded. DesignCorrelational, cross-sectional. Patients and SettingParticipants in this study were 211 consecutive referrals presenting to a university hospital pain management and research center, all of whom had a chronic pain problem. ResultsOverall, chronic pain patients who catastrophize reported more pain intensity, felt more disabled by their pain problem, and experienced more psychological distress. Regression analyses revealed that catastrophizing was a potent predictor of pain intensity, disability, and psychological distress, even when controlled for physical impairment. No fundamental differences between the three subgroups were found in this respect. Finally, it was demonstrated that there was no relation between physical impairment and catastrophizing. ConclusionsIt was concluded that for different subgroups of chronic pain patients, catastrophizing plays a crucial role in the chronic pain experience, significantly contributing to the variance of pain intensity, pain-related disability, and psychological distress. These relations are not confounded by the level of physical impairment. Some clinical implications of the results are discussed. Finally, the authors concluded that these results support the validity of a cognitive–behavioral conceptualization of chronic pain–related disability.

Fear-avoidance model of chronic musculoskeletal pain: 12 years on.

It is widely acknowledged that pain is a universal experience that affects human beings across the life span, serving an important protective function. Typical protective behaviors are the withdrawal from the noxious stimulus, nonverbal expressions that signal others for impending harm, and verbal utterances. Some of these occur involuntarily, as a reflex, whereas other behaviors are more deliberate. However, there is accumulating evidence that it is not pain itself, but the meaning of pain that predicts the extent to which individuals engage in these protective behaviors [1,3]. About a decade ago, we summarized the research evidence supporting the role of fear of pain in the development of chronic pain disability, presented a model incorporating basic mechanisms, but also noted a number of unresolved issues that called for further scientific attention [39] (Fig. 1). In the last decade, the number of studies on this subject has increased exponentially [21], and novel directions are being proposed [6]. Two main stances have emerged. First, although pain has intrinsic threatening features, the threat value of similar pain stimulus may vary across contexts and individuals. Second, protective responding may be adaptive in the short term, but may paradoxically worsen the problem in the long term. In the current updated review, we briefly summarize the progress made since, and highlight a selected number of remaining challenges and areas for future research.

Graded exposure in vivo in the treatment of pain-related fear : a replicated single-case experimental design in four patients with chronic low back pain

The aim of this investigation was to examine the effectiveness of a graded exposure in vivo treatment with behavioural experiments as compared to usual graded activity in reducing pain-related fears, catastrophising and pain disability in chronic low back pain patients reporting substantial fear of movement/(re)injury. Included in the study were four consecutive CLBP patients who were referred for outpatient behavioural rehabilitation, and who reported substantial fear of movement/(re)injury (Tampa Scale for Kinesiophobia score>40). A replicated single-case cross-over design was used. After a no-treatment baseline measurement period, the patients were randomly assigned to one of two interventions. In intervention A, patients received the exposure first, followed by graded activity. In intervention B, the sequence of treatment modules was reversed. Sixty-three daily measures of pain-related cognitions and fears were recorded with visual analogue scales. Before and after the treatment, the following measures were taken: pain-related fear, pain catastrophising, pain control and pain disability. Using time series analysis on the daily measures of pain-related cognitions and fears, we found that improvements only occurred during the graded exposure in vivo, and not during the graded activity, irrespective of the treatment order. Analysis of the pre-post treatment differences also revealed that decreases in pain-related fear concurred with decreases in pain catastrophising and pain disability, and in half of the cases an increase in pain control. This study shows that the external validity of exposure in vivo also extends to the subgroup of chronic low back pain patients who report substantial fear of movement/(re)injury.

Fear-avoidance model of chronic pain: the next generation.

Objective:The fear-avoidance (FA) model of chronic pain describes how individuals experiencing acute pain may become trapped into a vicious circle of chronic disability and suffering. We propose to extend the FA model by adopting a motivational perspective on chronic pain and disability. Methods:A narrative review. Results:There is ample evidence to support the validity of the FA model as originally formulated. There are, however, some key challenges that call for a next generation of the FA model. First, the FA model has its roots in psychopathology, and investigators will have to find a way to account for findings that do not easily fit within such framework. Second, the FA model needs to address the dynamics and complexities of disability and functional recovery. Third, the FA model should incorporate the idea that pain-related fear and avoidance occurs in a context of multiple and often competing personal goals. Discussion:To address these 3 key challenges, we argue that the next generation of the FA model needs to more explicitly adopt a motivational perspective, one that is built around the organizing powers of goals and self-regulatory processes. Using this framework, the FA model is recast as capturing the persistent but futile attempts to solve pain-related problems to protect and restore life goals.

Exposure in vivo versus operant graded activity in chronic low back pain patients: Results of a randomized controlled trial

&NA; 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.

A classification of chronic pain for ICD-11

Chronic pain has been recognized as pain that persists past normal healing time5 and hence lacks the acute warning function of physiological nociception.35 Usually pain is regarded as chronic when it lasts or recurs for more than 3 to 6 months.29 Chronic pain is a frequent condition, affecting an estimated 20% of people worldwide6,13,14,18 and accounting for 15% to 20% of physician visits.25,28 Chronic pain should receive greater attention as a global health priority because adequate pain treatment is a human right, and it is the duty of any health care system to provide it.4,13 The current version of the International Classification of Diseases (ICD) of the World Health Organization (WHO) includes some diagnostic codes for chronic pain conditions, but these diagnoses do not reflect the actual epidemiology of chronic pain, nor are they categorized in a systematic manner. The ICD is the preeminent tool for coding diagnoses and documenting investigations or therapeutic measures within the health care systems of many countries. In addition, ICD codes are commonly used to report target diseases and comorbidities of participants in clinical research. Consequently, the current lack of adequate coding in the ICD makes the acquisition of accurate epidemiological data related to chronic pain difficult, prevents adequate billing for health care expenses related to pain treatment, and hinders the development and implementation of new therapies.10,11,16,23,27,31,37 Responding to these shortcomings, the International Association for the Study of Pain (IASP) contacted the WHO and established a Task Force for the Classification of Chronic Pain. The IASP Task Force, which comprises pain experts from across the globe,19 has developed a new and pragmatic classification of chronic pain for the upcoming 11th revision of the ICD. The goal is to create a classification system that is applicable in primary care and in clinical settings for specialized pain management. A major challenge in this process was finding a rational principle of classification that suits the different types of chronic pain and fits into the general ICD-11 framework. Pain categories are variably defined based on the perceived location (headache), etiology (cancer pain), or the primarily affected anatomical system (neuropathic pain). Some diagnoses of pain defy these classification principles (fibromyalgia). This problem is not unique to the classification of pain, but exists throughout the ICD. The IASP Task Force decided to give first priority to pain etiology, followed by underlying pathophysiological mechanisms, and finally the body site. Developing this multilayered classification was greatly facilitated by a novel principle of assigning diagnostic codes in ICD-11, termed “multiple parenting.” Multiple parenting allows the same diagnosis to be subsumed under more than 1 category (for a glossary of ICD terms refer to Table ​Table1).1). Each diagnosis retains 1 category as primary parent, but is cross-referenced to other categories that function as secondary parents. Table 1 Glossary of ICD-11 terms. The new ICD category for “Chronic Pain” comprises the most common clinically relevant disorders. These disorders were divided into 7 groups (Fig. ​(Fig.1):1): (1) chronic primary pain, (2) chronic cancer pain, (3) chronic posttraumatic and postsurgical pain, (4) chronic neuropathic pain, (5) chronic headache and orofacial pain, (6) chronic visceral pain, and (7) chronic musculoskeletal pain. Experts assigned to each group are responsible for the definition of diagnostic criteria and the selection of the diagnoses to be included under these subcategories of chronic pain. Thanks to Bedirhan Ustun and Robert Jakob of the WHO, these pain diagnoses are now integrated in the beta version of ICD-11 (http://id.who.int/icd/entity/1581976053). The Task Force is generating content models for single entities to describe their clinical characteristics. After peer review overseen by the WHO Steering Committee,39 the classification of chronic pain will be voted into action by the World Health Assembly in 2017. Figure 1 Organizational chart of Task Force, IASP, and WHO interactions. The IASP Task Force was created by the IASP council and its scope defined in direct consultation of the chairs (R.D.T. and W.R.) with WHO representatives in 2012. The Task Force reports to ... 2. Classification of chronic pain Chronic pain was defined as persistent or recurrent pain lasting longer than 3 months. This definition according to pain duration has the advantage that it is clear and operationalized. Optional specifiers for each diagnosis record evidence of psychosocial factors and the severity of the pain. Pain severity can be graded based on pain intensity, pain-related distress, and functional impairment. 2.1. Chronic primary pain Chronic primary pain is pain in 1 or more anatomic regions that persists or recurs for longer than 3 months and is associated with significant emotional distress or significant functional disability (interference with activities of daily life and participation in social roles) and that cannot be better explained by another chronic pain condition. This is a new phenomenological definition, created because the etiology is unknown for many forms of chronic pain. Common conditions such as, eg, back pain that is neither identified as musculoskeletal or neuropathic pain, chronic widespread pain, fibromyalgia, and irritable bowel syndrome will be found in this section and biological findings contributing to the pain problem may or may not be present. The term “primary pain” was chosen in close liaison with the ICD-11 revision committee, who felt this was the most widely acceptable term, in particular, from a nonspecialist perspective.

Confirmatory factor analysis of the Tampa Scale for Kinesiophobia: invariant two-factor model across low back pain patients and fibromyalgia patients.

Objectives(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. Patients and MethodsTSK-data from 8 studies collected in Dutch and Flemish chronic pain patients were pooled. For 188 CLBP patients and 89 FM patients, complete data were available. Confirmatory factor analyses were performed to assess 4 models of kinesiophobia, and to examine which factor model provided the best fit. Furthermore, a multi-sample analysis was performed to investigate the stability of the factor structure in both patient groups. ResultsFor both CLBP and FM patients, the 2-factor model containing the factors “activity avoidance” and “pathologic somatic focus” was superior as compared with the 4-factor model containing the factors “harm,” “fear of (re)injury.” “importance of exercise,” and “avoidance of activity”. Moreover, the 2-factor model was found to be invariant across CLBP and FM patients, indicating that this model is robust in both pain samples. DiscussionAs the 2-factor structure provided the best fit of the data in both patient samples, we recommend to use this version of the TSK and its 2 subscales in both clinical practice and research. Based on the content of the items, the subscales were labeled “Harm” and “Fear-avoidance.”