Katja Boersma

The Fear-Avoidance Model of Musculoskeletal Pain: Current State of Scientific Evidence

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.

Early identification of patients at risk of developing a persistent back problem: the predictive validity of the Orebro Musculoskeletal Pain Questionnaire.

ObjectiveTo test the predictive utility of the Örebro Musculoskeletal Pain Screening Questionnaire in identifying patients at risk for developing persistent back pain problems. DesignProspective, where participants completed the questionnaire and their cases were followed for 6 months to assess outcome with regard to pain, function, and absenteeism due to sickness. ParticipantsOne hundred seven patients, recruited from seven primary care units. ResultsDiscriminant analyses showed that the items on the questionnaire were significantly related to future problems. For absenteeism due to sickness, 68% of the patients were correctly classified into one of three groups, whereas an even distribution would have produced 33%. The analyses for function correctly classified 81%, and for pain 71%, into one of two groups, compared with a chance level of 50%. A total score analysis demonstrated that a cutoff score of 90 points had a sensitivity of 89% and a specificity of 65% for absenteeism due to sickness, and a sensitivity of 74% and a specificity of 79% for functional ability. ConclusionsThe results underscore that psychological variables are related to outcome 6 months later, and they replicate and extend earlier findings indicating that the Örebro Screening Questionnaire is a clinically reliable and valid instrument. The total score was a relatively good predictor of future absenteeism due to sickness as well as function, but not of pain. The results suggest that the instrument could be of value in isolating patients in need of early interventions and may promote the use of appropriate interventions for patients with psychological risk factors.

Screening to Identify Patients at Risk: Profiles of Psychological Risk Factors for Early Intervention.

There is a serious need to provide effective early interventions that prevent the development of persistent pain and disability. Identifying patients at risk for this development is an important step. Our aim was to explore whether distinct subgroups of individuals with similar response patterns on a screening questionnaire exist. Moreover, the objective was to then relate these groups to future outcomes, for example, sick leave as an impetus for developing tailored interventions that might better prevent chronic problems. A total of 363 patients seeking primary care for acute or subacute spinal pain completed the Örebro Musculoskeletal Pain Screening Questionnaire and were then followed to determine outcome. Cluster analysis was used to identify subgroups. Validity was tested using 3 methods including the split-half technique. The subgroups were compared prospectively on outcome measures obtained 1 year later. Using pain intensity, fear-avoidance beliefs, function, and mood, we found 4 distinct profiles: Fear-Avoidant, Distressed Fear-Avoidant, Low Risk, and Low Risk-Depressed Mood. These 4 subgroups were also robust in all 3 of the validity procedures. The 4 subgroups were clearly related to outcome. Although the low risk profiles had virtually no one developing long-term sick leave, the Fear-Avoidant profile had 35% and the Distressed Fear-Avoidant profile 62% developing long-term sick leave. Our results suggest that fear-avoidance and distress are important factors in the development of pain-related disability and may serve as a key for early identification. Providing interventions specific to the factors isolated in the profiles should enhance the prevention of persistent pain and disability.

Lowering fear-avoidance and enhancing function through exposure in vivo : a multiple baseline study across six patients with back pain

&NA; 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.

The Effects of Cognitive-behavioral and Physical Therapy Preventive Interventions on Pain-related Sick Leave: A Randomized Controlled Trial

Objective: Recent recommendations suggest that reassuring patients with an acute bout of low back pain and encouraging a return to normal activities may be helpful in preventing the development of chronic disability. There is also a question as to whether psychologic or physical therapy interventions actually add anything to such reassurance and advice in terms of preventing chronicity. This study aimed to ascertain the preventive effects on future sick leave and health-care utilization of adding on a cognitive-behavioral group intervention or a cognitive-behavioral group intervention and preventive physical therapy (focused on activity and exercise) relative to a minimal treatment group (examination, reassurance, and activity advice). Subjects: A total of 185 patients seeking care for nonspecific back or neck pain who were employed and at risk for developing long-term disability volunteered to participate in the study. Of these 185, 158 (85%) completed the pre- and 1-year follow-up assessments. Results: Significant differences were observed on the key outcome variables of future health-care utilization and work absenteeism. For health-care utilization, the cognitive-behavioral intervention group and preventive physical therapy group had significantly fewer healthcare visits than did the Minimal Treatment Group. For work absenteeism, the cognitive-behavioral intervention group and cognitive-behavioral intervention and preventive physical therapy group had fewer days during the 12-month follow-up than did the Minimal Treatment Group. The risk for developing long-term sick disability leave was more than five-fold higher in the Minimal Group as compared with the other 2 groups. However, there was no difference between the cognitive-behavioral intervention group and cognitive-behavioral intervention and preventive physical therapy group on sick leave. Conclusion: Taken as a whole, this study shows that adding cognitive-behavioral intervention and cognitive-behavioral intervention and preventive physical therapy can enhance the prevention of long-term disability. There was no substantial difference in the results between the cognitive-behavioral intervention group and cognitive-behavioral intervention and preventive physical therapy group.

Fear of movement and (re)injury in chronic musculoskeletal pain: Evidence for an invariant two-factor model of the Tampa Scale for Kinesiophobia across pain diagnoses and Dutch, Swedish, and Canadian samples

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.

Expectancy, fear and pain in the prediction of chronic pain and disability: a prospective analysis.

Studies with (sub) acute back pain patients show that negative expectancies predict pain and disability at a one‐year follow up. Yet, it is not clear how expectations relate to other factors in the development of chronic disability such as pain and fear. This study investigates the relationship between expectations, pain‐related fear and pain and studies how these variables are related to the development of chronic pain and disability. Subjects (N = 141) with back and/or neck pain (duration <1 year) were recruited via primary care. They completed measures on pain, expectancy, pain‐related fear (pain‐related negative affect and fear avoidance beliefs) and function. A one‐year follow up was conducted with regard to pain and function. It was found that pain, expectancy, pain‐related fear and function were strongly interrelated. In the cross‐sectional analyses negative expectancies were best explained by frequent pain and a belief in an underlying and serious medical problem. Prospectively, negative expectancy, negative affect and a belief that activity may result in (re) injury or increased pain, explained unique variance in both pain and function at one‐year follow up. In conclusion, expectancy, negative affect and fear avoidance beliefs are interrelated constructs that have predictive value for future pain and disability. Clinically, it can be helpful to inquire about beliefs, expectancy and distress as an indication of risk as well as to guide intervention. However, the strong interrelations between the variables call for precaution in treating them as if they were separate entities existing in reality.

Psychological processes underlying the development of a chronic pain problem: a prospective study of the relationship between profiles of psychological variables in the fear-avoidance model and disability.

Objectives:Understanding the psychological processes that underlie the development of a chronic pain problem is important to improve prevention and treatment. The aim of this study was to test whether distinct profiles of variables within the fear-avoidance model could be identified and could be related to disability in a meaningful way. Methods:In 81 persons with a musculoskeletal pain problem, cluster analysis was used to identify subgroups with similar patterns on fear and avoidance beliefs, catastrophizing, and depression. The clusters were examined cross-sectionally and prospectively on function, pain, health care usage, and sick leave. Results:Five distinct profiles were found: pain-related fear, pain-related fear + depressed mood, medium pain-related fear, depressed mood, and low risk. These subgroups were clearly related to outcome. In contrast to the clusters “medium pain-related fear” and “low risk,” the majority of those classified in the clusters “pain-related fear,” “pain-related fear + depressed mood,” and “depressed mood” reported long-term sick leave during follow-up. The subjects in the clusters with high scores on the depression measure reported the highest percentage of health care usage during follow-up (70% in the “pain-related fear + depressed mood” group and 42% in the “depressed mood” group reported >10 health care visits). Conclusions:Distinct profiles of psychological functioning could be extracted and meaningfully related to future disability. These profiles give support to the fear-avoidance model and underscore the need to address the psychological aspects of the pain experience early on.

Manipulating optimism: Can imagining a best possible self be used to increase positive future expectancies?

This study tested whether a brief manipulation consisting of positive future thinking can temporarily increase optimism. Participants in the positive future thinking condition (n = 44) wrote about their best possible self (BPS) for 15 min, followed by 5 min of mental imagery. Participants in the control condition (n = 38) wrote about and imagined a typical day in their life. Positive and negative future expectancies and positive and negative affect were measured before and after each manipulation. Compared to the control manipulation, the positive future thinking manipulation led to significantly larger increase in positive affect and positive future expectancies. The increase in positive expectancies was not dependent on the mood effect. The results indicate that imagining a positive future can indeed increase expectancies for a positive future.

The role of depression and catastrophizing in musculoskeletal pain.

Many patients with musculoskeletal pain also suffer from a depressed mood. Catastrophizing is one process that may link depression and pain since it is a key concept in models of both problems. Earlier research has suggested that catastrophizing measures something above and beyond depression. This study tests the idea that if depressed mood and catastrophizing are separate entities then when one is absent the other should still contribute to poor outcome, and, when both are present there should be an additional adverse effect. To this end, a prospective design, with a built-in replication from two clinical samples of patients with sub-acute pain (one from Sweden, N=373; one from Australasia, N=259), was employed. Participants were classified as to having high/low scores on measures of depression and catastrophizing. Subsequently, these classifications were studied in relation to outcome variables cross-sectionally and at follow-up. Results showed a small to moderate correlation between catastrophizing and depression and that there are individuals with one, but not the other problem. Further, having one or the other of the entities was associated with current pain problems and outcome, while having both increased the associations substantially. The replication showed very similar results Our data demonstrate that pain catastrophizing and heightened depressed mood have an additive and adverse effect on the impact of pain, relative to either alone. It suggests that each should be assessed in the clinic and that future research should focus on treatments specifically designed to tackle both depressed mood and catastrophizing.Many patients with musculoskeletal pain also suffer from a depressed mood. Catastrophizing is one process that may link depression and pain since it is a key concept in models of both problems. Earlier research has suggested that catastrophizing measures something above and beyond depression. This study tests the idea that if depressed mood and catastrophizing are separate entities then when one is absent the other should still contribute to poor outcome, and, when both are present there should be an additional adverse effect.