Maaike Leeuw

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.

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.

Fear of movement/injury in the general population: Factor structure and psychometric properties of an adapted version of the Tampa Scale for Kinesiophobia

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.

Measuring Fear of Movement/(Re)injury in Chronic Low Back Pain Using Implicit Measures

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.

994 IS GRADED EXPOSURE IN VIVO COST‐EFFECTIVE? AN ECONOMIC EVALUATION STUDY IN CHRONIC LOW BACK PAIN

Background and Aim: ESWL is an effective method of treatment for urinary calculi, and a mildly painful procedure that requires conscious sedation. Intravenous sedoanalgesia techniques are preferred. Bronchial asthma, nasal polyposis, and intolerance to aspirin are determined as Samter’s Syndrome. We present a regional anesthesia choice instead of sedoanalgesia technique for an ESWL patient with Samter’s syndrome. Case: A 38-year-old woman was admitted with a mild pain on left lumbar side. Left renal stone (15×9mm) was diagnosed and ESWL was planned. History and physical examination revealed Samter’s Syndrome, panic disorder and morbid obesity (BMI = 42kg/m). Spinal anesthesia was preferred to prevent pain during ESWL although sedoanalgesia technique is widely performed in our clinic. After midazolam (2mg, IV) administration, oxygen and standard monitoring was applied. Spinal anesthesia was performed using midline technique (L3–4) with a 25-gauge needle (Quincke). After bupivacaine (0.5%, 3 cc) injection, spinal needle was withdrawn. No supplemental IV opioids were required and patient was comfortable during anesthesia. Recovery period was uneventful, sensory and motor blockade was resolved completely following 180 minute of anesthesia and the patient was discharged when all criteria were met. Discussion and Conclusion: The potential advantages of regional anesthesia include minimal airway intervention, less cardiopulmonary depression, effective postoperative analgesia, less postoperative nausea and vomiting, and shorter hospital stay. In conclusion, we suggest that spinal anesthesia should be considered as an option of successful anesthesia management for an ESWL patient who is suffering from Samter’s syndrome, extreme obesity, irritable airway and panic disorder.