Abstract
BackgroundChronic low back pain is a worldwide burden that is not being abated with our current knowledge and treatment of the condition. The fear-avoidance model is used to explain the relationship between pain and disability in patients with chronic low back pain. However there are gaps in empirical support for pathways proposed within this model, and no evidence exists as to whether physical activity moderates these pathways.MethodsThis was a cross-sectional study of 218 people with chronic low back pain. Multiple mediation analyses were conducted to determine the role of fear, catastrophizing, depression, and anxiety in the relationship between pain and disability. Separate analyses were performed with physical activity as the moderator. Individuals were classified as performing regular structured physical activity if they described on average once per week for > 30-minutes an activity classified at least moderate intensity (≥ 4–6 METs), activity prescribed by an allied health professional for their back pain, leisure time sport or recreation, or self-directed physical activity such as resistance exercise.ResultsFear, catastrophizing, and depression significantly mediated the relationship between pain and disability (p<0.001). However the mediating effect of catastrophizing was conditional upon weekly physical activity. That is, the indirect effect for catastrophizing mediating the relationship between pain and disability was only significant for individuals reporting weekly physical activity (B = 1.31, 95% CI 0.44 to 2.23), compared to individuals reporting no weekly physical activity (B = 0.21, 95% CI -0.50 to 0.97). Catastrophizing also mediated the relationship between pain and fear (B = 0.37, 95% CI 0.15 to 0.62), with higher scores explaining 53% of the total effect of pain on fear.ConclusionsThese results support previous findings about the importance of fear and depression as factors that should be targeted in low back pain patients to reduce back pain related disability. We have also extended understanding for the mediating effect of catastrophizing on back pain related disability. Back pain patients engaged with regular physical activity may require counselling with regards to negative pain perceptions.
Highlights
Low back pain is the musculoskeletal condition with the greatest worldwide burden of disease, defined in terms of disability adjusted life years or years lived with disability [1]
Hospital Anxiety and Depression Scale (HADS)-a, Hospital Depression and Anxiety Scale – anxiety; HADS-d, Hospital Depression and Anxiety Scale – depression; LBP, low back pain; METS, metabolic equivalents; Oswestry Low Back Pain Disability Index (ODI), Oswestry disability index; Pain Catastrophizing Scale (PCS), pain catastrophizing scale; VAS-c, visual analog pain scale - current pain; VAS-w, visual analog pain scale - worse pain last week. These results support previous findings about the importance of fear and depression as factors that should be targeted in low back pain patients to reduce back pain related disability
We have extended understanding for the mediating effect of catastrophizing on back pain related disability
Summary
Low back pain is the musculoskeletal condition with the greatest worldwide burden of disease, defined in terms of disability adjusted life years or years lived with disability [1]. The economic cost to society is considerable, with direct annual costs of treatment in Australia estimated to be $4.8 billion [2], and total treatment costs approximately $9 billion [3]. Despite both pain and disability being associated with a range of psychosocial and physical factors [4,5,6,7], the direct pathways that link pain and disability remain unclear. Despite its popularity for explaining disability, and integration into clinical trials to provide measures of treatment action, there are gaps in empirical support for pathways within the fear-avoidance model
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