Mari Lundberg

Pain-related fear: A critical review of the related measures

Objectives: In regards to pain-related fear, this study aimed to: (1) identify existing measures and review their measurement properties, and (2) identify the optimum measure for specific constructs of fear-avoidance, pain-related fear, fear of movement, and kinesiophobia. Design: Systematic literature search for instruments designed to measure fear of pain in patients with persistent musculoskeletal pain. Psychometric properties were evaluated by adjusted Wind criteria. Results: Five questionnaires (Fear-Avoidance Beliefs Questionnaire (FABQ), Fear-Avoidance of Pain Scale (FAPS), Fear of Pain Questionnaire (FPQ), Pain and Anxiety Symptoms Scale (PASS), and the Tampa Scale for Kinesiophobia (TSK)) were included in the review. The main findings were that for most questionnaires, there was no underlying conceptual model to support the questionnaires construct. Psychometric properties were evaluated by diverse methods, which complicated comparisons of different versions of the same questionnaires. Construct validity and responsiveness was generally not supported and/or untested. Conclusion: The weak construct validity implies that no measure can currently identify who is fearful. The lack of evidence for responsiveness restricts the current use of the instruments to identify clinically relevant change from treatment. Finally, more theoretically driven research is needed to support the construct and thus the measurement of pain-related fear.

Fear of movement and avoidance behaviour toward physical activity in chronic-fatigue syndrome and fibromyalgia: state of the art and implications for clinical practice

Severe exacerbation of symptoms following physical activity is characteristic for chronic-fatigue syndrome (CFS) and fibromyalgia (FM). These exacerbations make it understandable for people with CFS and FM to develop fear of performing body movement or physical activity and consequently avoidance behaviour toward physical activity. The aims of this article were to review what measures are available for measuring fear of movement and avoidance behaviour, the prevalence fear of movement and avoidance behaviour toward physical activity and the therapeutic options with fear of movement and avoidance behaviour toward physical activity in patients with CFS and FM. The review revealed that fear of movement and avoidance behaviour toward physical activity is highly prevalent in both the CFS and FM population, and it is related to various clinical characteristics of CFS and FM, including symptom severity and self-reported quality of life and disability. It appears to be crucial for treatment (success) to identify CFS and FM patients displaying fear of movement and avoidance behaviour toward physical activity. Individually tailored cognitive behavioural therapy plus exercise training, depending on the patient’s classification as avoiding or persisting, appears to be the most promising strategy for treating fear of movement and avoidance behaviour toward physical activity in patients with CFS and FM.

The Majority of Patients With Achilles Tendinopathy Recover Fully When Treated With Exercise Alone A 5-Year Follow-Up

Background: Systematic reviews indicate that exercise has the most evidence of effectiveness in treatment of midportion Achilles tendinopathy. However, there is a lack of long-term follow-ups (>4 years). Purpose: To evaluate the 5-year outcome of patients treated with exercise alone and to examine if certain characteristics, such as level of kinesiophobia, age, and sex, were related to the effectiveness of the treatment. Study Design: Case series; Level of evidence, 4. Methods: Thirty-four patients (47% women), 51 ± 8.2 years old, were evaluated 5 years after initiation of treatment. The evaluation consisted of a questionnaire regarding recovery of symptoms and other treatments, the Victorian Institute of Sports Assessment–Achilles questionnaire (VISA-A) for symptoms, the Tampa Scale for Kinesiophobia, and tests of lower leg function. Results: Twenty-seven patients (80%) fully recovered from the initial injury; of these, 22 (65%) had no symptoms, and 5 (15%) had a new occurrence of symptoms. Seven patients (20%) had continued symptoms. Only 2 patients received another treatment (acupuncture and further exercise instruction). When compared with the other groups, the continued-symptoms group had lower VISA-A scores (P = .008 to .021) at the 5-year follow-up and the previous 1-year follow-up but not at any earlier evaluations. There were no significant differences among the groups in regard to sex, age, or physical activity level before injury. There was a significant (P = .005) negative correlation (−0.590) between the level of kinesiophobia and heel-rise work recovery. Conclusion: The majority of patients with Achilles tendinopathy in this study fully recovered in regard to both symptoms and function when treated with exercise alone. Increased fear of movement might have a negative effect on the effectiveness of exercise treatment; therefore, a pain-monitoring model should be used when patients are treated with exercise.

My prosthesis as a part of me: a qualitative analysis of living with an osseointegrated prosthetic limb:

Background: Bone-anchored prosthesis is still a rather unusual treatment for patients with limb loss. Objectives: The aim of this study was to improve our understanding about the experience of living with an osseointegrated prosthesis (OI-prosthesis) compared to one suspended with a socket, through the use of qualitative research methodology. Study design: A qualitative phenomenological research method. Methods: Thirteen Swedish patients (37–67 years) with unilateral upper or lower limb amputation (10 transfemoral, 2 transhumeral, 1 transradial), who had been using OI-prostheses for 3 to 15 years, were recruited by means of purposive sampling. An audio-taped in-depth interview was performed. The guiding question was ‘How do you experience living with your osseointegrated prosthesis compared to your earlier prostheses suspended with sockets?’. The empirical phenomenological psychological method was used for data analysis. Results: The results showed that all participants described living with an OI-prosthesis as a revolutionary change. These experiences were described in terms of three typologies, called ‘Practical prosthesis’, ‘Pretend limb’ and ‘A part of me’. Conclusions: The most important finding was that the change went beyond the functional improvements, integrating the existential implications in the concept of quality of life. Clinical relevance This qualitative in-depth interview study on patients using bone-anchored prosthetic limbs showed that all described a revolutionary change in their lives as amputees and the meaning of that change went beyond the functional improvements, integrating existential implications in the concept of quality of life.

KINESIOPHOBIA AMONG PATIENTS WITH MUSCULOSKELETAL PAIN IN PRIMARY HEALTHCARE

OBJECTIVES To describe the occurrence of kinesiophobia and to investigate the association between kinesiphobia and pain variables, physical exercise measures and psychological characteristics in patients with musculoskeletal pain. DESIGN A prospective descriptive study involving 2 selected physiotherapy departments within a primary healthcare setting in the south-west of Sweden. PATIENTS Included were 140 of 369 (38%) consecutive patients (aged between 18 and 65 years) with musculoskeletal pain. METHODS Questionnaires including background data, pain variables, physical exercise measures and psychological characteristics were sent to the patients prior to their appointment with the physiotherapist. A simple and a multiple logistic regression model were performed to identify associations among the variables where kinesiophobia was defined as the dependent variable. RESULTS A high degree of kinesiophobia and psychological distress were observed in approximately 50% of the responders. According to the simple logistic regression analysis the factors that seemed to be associated with kinesiophobia were interference, disability, pain severity, pain intensity, life control, affective distress, depressed mood and solicitous response. The multiple logistic regression analysis showed no significant associations. CONCLUSION Kinesiophobia is a commonly seen factor among patients with musculoskeletal pain, which ought to be taken into consideration when designing and performing rehabilitation programmes.

Ability to perform a single heel-rise is significantly related to patient-reported outcome after Achilles tendon rupture

This study evaluated the short‐term recovery of function after an acute Achilles tendon rupture, measured by a single‐legged heel‐rise test, with main emphasis on the relation to the patient‐reported outcomes and fear of physical activity and movement (kinesiophobia). Eighty‐one patients treated surgically or non‐surgically with early active rehabilitation after Achilles tendon rupture were included in the study. Patients ability to perform a single‐legged heel‐rise, physical activity level, patient‐reported symptoms, general health, and kinesiophobia was evaluated 12 weeks after the injury. The heel‐rise test showed that 40 out of 81 (49%) patients were unable to perform a single heel‐rise 12 weeks after the injury. We found that patients who were able to perform a heel‐rise were significantly younger, more often of male gender, reported a lesser degree of symptoms, and also had a higher degree of physical activity at 12 weeks. There was also a significant negative correlation between kinesiophobia and all the patient‐reported outcomes and the physical activity level. The heel‐rise ability appears to be an important early achievement and reflects the general level of healing, which influences patient‐reported outcome and physical activity. Future treatment protocols focusing on regaining strength early after the injury therefore seem to be of great importance. Kinesiophobia needs to be addressed early during the rehabilitation process.

On what patients does the Tampa Scale for Kinesiophobia fit

The Tampa Scale of Kinesiophobia (TSK) has been used for a decade and is a valuable tool in researching pain-related fear. A variety of different factor models exist, however, and there are inconsistencies as to which model to use. The purpose of the study was twofold: 1) to thoroughly review existing factor models and 2) to empirically evaluate the previously proposed factor models in a large sample with persistent musculoskeletal pain. Subjects included 578 of 711 (81%) consecutive patients (aged 18-65 years) with persistent musculoskeletal pain from three different orthopedic outpatient clinics. We reviewed all existing factor models and performed confirmatory factor analyses on the existing models. Our review identified 11 factor models of the TSK. The identified models were tested on a large Swedish sample. All models were rejected because of unacceptable goodness-of-fit statistics in that specific sample. This study supports the fact that TSK is a multidimensional construct. Rather than searching for new factor solutions, future research should be devoted to forming a consensus for the conceptual and operational definitions of the construct kinesiophobia and the application of the Tampa Scale for Kinesiophobia. Physiotherapists are encouraged to take part in building new theories.

The impact of fear-avoidance model variables on disability in patients with specific or nonspecific chronic low back pain.

Study Design. A prospective cross-sectional design. Objective. The objectives were to describe the occurrence and to investigate the association of the fear-avoidance model variables (pain intensity, kinesiophobia, depression, and disability) in patients with specific or nonspecific chronic low back pain (CLBP). Summary of Background Data. Affective factors, particularly fear, have proven to be central in the explanation and understanding of chronic pain. The fear-avoidance model has shown that fearful patients with CLBP are at risk of becoming trapped in a vicious cycle of pain, fear, disability, and depressive symptoms. Little is known about the relationship between these factors in patients subgrouped as specific or nonspecific CLBP. Methods. All 147 patients (81 women and 66 men) were examined by an orthopedic surgeon and diagnosed as either specific or nonspecific CLBP on the basis of that examination. Hierarchical multiple regression analysis was used to assess the ability of three independent variables (back pain intensity, VAS; kinesiophobia, TSK; depressed mood, Zung) to predict levels of disability after controlling for the influence of age and sex. Results. Both groups (specific and nonspecific CLBP) presented elevated values on the fear-avoidance model variables. All the independent fear-avoidance variables contributed in a statistically significant manner to predict disability in patients with specific CLBP, 67.0%, F (5, 59) = 24.46, P < 0.000. In patients with nonspecific CLBP, all variables except kinesiophobia predicted disability in a statistically significant manner, 63.0%, F (5, 59) = 22.64, P < 0.000. Conclusion. We conclude that persistent musculoskeletal pain affects the individual in a similar manner, regardless of the cause of the pain. In clinical terms, this means that pain must be analyzed and treated as a parallel process to searching for the cause of the pain.

The impact on kinesiophobia (fear of movement) by clinical variables for patients with coronary artery disease.

BACKGROUND The impact on kinesiophobia (fear of movement) for patients with coronary artery disease (CAD) is not known. The aims were to describe the occurrence of kinesiophobia in patients with CAD, and to investigate the influence on kinesiophobia by clinical variables. MATERIALS AND METHODS In total, 332 patients, mean age, 65 ± 9.1 years diagnosed with CAD at a university hospital were included in the study. The Tampa Scale for Kinesiophobia Heart (TSK-SV Heart) was used to assess kinesiophobia. Comparisons between high versus low levels of kinesiophobia were measured for each variable. Binary logistic regression analyses were performed with a high level of kinesiophobia (TSK-SV Heart>37) as dependent variable, and with the observed variables as independent. The study had an exploratory, cross-sectional design. RESULTS A high level of kinesiophobia was found in 20% of the patients. The following variables decreased the odds ratio (OR) for a high level of kinesiophobia: Attending cardiac rehabilitation (yes vs no: -56.7%), level of physical activity (medium vs high: -80.8%), Short-Form 36: general health (-4.3%), physical functioning (-1.8%). Two variables increased the OR for a high level of kinesiophobia: heart failure as complication at hospital (yes vs no: 418.7%), anxiety (19.2%). Previous heart failure (yes vs no) was unexpectedly found to reduce kinesiophobia (-88.3%) due to suppression. CONCLUSIONS Several important clinical findings with impact on rehabilitation and prognosis for patients with CAD were found to be associated with a high level of kinesiophobia. Therefore, kinesiophobia needs to be considered in secondary prevention for patients with CAD.

Change in kinesiophobia and its relation to activity limitation after multidisciplinary rehabilitation in patients with chronic back pain

Purpose: To explore the change in kinesiophobia in relation to activity limitation after a multidisciplinary rehabilitation programme in patients with chronic back pain. Method: A prospective cohort study was made including 265 patients. Data were collected at baseline, after rehabilitation, and at 6-months follow-up. Outcome measures were the Tampa Scale for kinesiophobia (TSK) and the disability rating index (DRI). The smallest detectable change (SDC) in TSK was set to 8 scores. Relationships between kinesiophobia and activity limitation/physical ability were explored with regard to subgroups with high, medium and low baseline TSK scores, and for those patients who did or did not reach the SDC in TSK. Results: Improvements in TSK showed high effect sizes in the groups with high and medium baseline TSK scores. Improvements in DRI showed medium effect sizes in all three TSK subgroups. One third of the patients reached the SDC in TSK, and this group also improved significantly more in DRI. The correlation between change in TSK and change in DRI was low. Half of the patients with high TSK score at baseline remained having high DRI at follow-up. Conclusions: Improvement in physical ability was not related to the initial degree of kinesiophobia but to the SDC in TSK. To prevent patients with high kinesiophobia from preserving high activity limitations, it might be useful to include targeted treatment of kinesiophobia. Implications for Rehabilitation Intensive multidisciplinary rehabilitation decreases kinesiophobia and activity limitation in patients with chronic back pain. Patients improving >8 scores on the Tampa Scale for kinesiophobia are likely to increase their physical ability. Patients with an initially high degree of kinesiophobia as well as a high level of activity limitation need targeted treatment of kinesiophobia to increase their physical ability.