Pain-related Fear Of Movement Research Articles

Pain Education and Virtual Reality Improves Pain, Pain-related Fear of Movement, and Trunk Kinematics in Individuals with Persistent Low Back Pain.

To evaluate the effect of combining pain education and virtual reality exposure therapy using a cognitive behavioural therapy-informed approach (VR-CBT) on pain intensity, fear of movement, and trunk movement, in individuals with persistent low back pain. Thirty-seven participants were recruited in a single cohort repeated measures study, attending three sessions one week apart. The VR-CBT intervention included standardised pain education (Session 1), and virtual reality exposure therapy (Session 2) incorporating gameplay with mixed reality video capture and reflective feedback of performance. Outcome measures (Pain intensity, pain-related fear of movement (Tampa Scale of Kinesiophobia), and trunk kinematics during functional movements (maximum amplitude, peak velocity) were collected at baseline (Session1), and one week following education (Session 2) and virtual reality exposure therapy (Session 3). One-way repeated measures ANOVAs evaluated change in outcomes from baseline to completion. Post-hoc contrasts evaluated effect sizes for the education and virtual reality components of VR-CBT. Thirty-four participants completed all sessions. Significant (P<0.001) reductions were observed in Mean(SD) pain (baseline 5.9(1.5); completion 4.3(2.1)) and fear of movement (baseline 42.6(6.4); completion 34.3(7.4)). Large effect sizes (Cohen's d) were observed for education (pain intensity 0.85; fear of movement 1.28) while the addition of virtual reality exposure therapy demonstrated very small insignificant effect sizes, (pain intensity 0.10; fear of movement 0.18). Peak trunk velocity, but not amplitude, increased significantly (P<0.05) across trunk movement tasks. A VR-CBT intervention improved pain, pain-related fear of movement, and trunk kinematics. Further research should explore increased VR-CBT dosage and mechanisms underlying improvement.

Postoperative Psychological Predictors for Chronic Postsurgical Pain After a Knee Arthroplasty: A Prospective Observational Study.

Chronic postsurgical pain (CPSP) is a significant adverse effect shown in around 20% of people who had undergone a knee arthroplasty (KA). Psychological risk factors have emerged as significant and potentially modifiable risk factors for its development. However, there is still little evidence when assessing these factors during the acute postoperative period. This study aimed to assess the predictive value of postoperative pain catastrophizing, pain-related fear of movement, anxiety, depression, and pain attitudes in developing CPSP after KA. A 6-month follow-up prospective observational study design was used. The study sample comprised 115 people who underwent a KA due to painful primary osteoarthritis. Measures of pain catastrophizing, pain-related fear of movement, anxiety, depression, and pain attitudes were obtained 1week after surgery. CPSP was set at an intensity of ≥30 using a 100-mm visual analog scale at 3 and 6months after surgery. Analysis revealed that baseline pain intensity, pain catastrophizing, pain-related fear of movement, anxiety, depression, and maladaptive pain attitudes were significant predictors of chronic pain at 3 and 6months after surgery in a univariate analysis. However, at 3months after surgery, only pain intensity and pain catastrophizing were predictors in the final multivariate model forecasting disturbing pain. Moreover, 6months after surgery, pain intensity and distrust in medical procedures remained independent predictors. Most of the psychological factors can be grouped into a single dimension defined as pain-related psychological distress. The results suggest that postoperative pain intensity, pain catastrophizing, and pain attitudes are independent predictors for CPSP after KA. Postoperative cognitive and emotional factors should be considered alongside pain intensity during postoperative rehabilitation after KA because they could influence the development of CPSP.

E092 Confirmatory factor analyses of the Tampa Scale of Kinesiophobia 11-item version and Pain Catastrophising Scale: A cross-sectional study in people living with axial spondyloarthritis

Abstract Background/Aims The Fear Avoidance Model (FAM) proposes pain-related fear of movement and pain catastrophising to be prominent psychological experiences that compromise physical function and activity behaviour in people living with chronic pain. Yet, little research has tested the FAM in people living with axial spondyloarthritis (axSpA) despite the evidenced benefits of physical activity and exercise. This study examines the structural aspect of construct validity of the 11-item Tampa Scale of Kinesiophobia (TSK-11) and Pain Catastrophising Sale (PCS) as an important first step, to establish valid measurement tools to effectively test the relevance of the FAM for people with axSpA. Methods An online survey was distributed via the National Axial Spondyloarthritis Society including the TSK-11 and PCS. Ninety-eight people with axSpA (M Age = 45.62 SD = 12.16, M BASFI = 3.7 SD = 2.60, Female = 70%, NSAID use = 58.76%, bDMARDS use = 62.24%) completed the survey (December 2020- April 2021). Internal consistency was examined via Cronbach alpha values and confirmatory factor analysis tested the TSK-11's two-factor structure and PCS's three-factor structure. A model has excellent fit to the data with values &amp;lt; 3 for the CMIN/DF, and around .95 for CFI, .06 for RMSEA, .08 for SRMR. Factor loadings &amp;lt; .40 support deletion. Results Alpha values supported the internal consistency of participant responses to the somatic (.78), avoidance behaviour (.80) and overall fear of movement (.89) TSK-11 items. Fit indices also showed a good fit to the data for the TSK-11’s two-factor structure once two error terms were correlated (CMIN/DF = 1.77/42, CFI = .93, RMSEA = .09 (.05 - .12), SRMR= .06). Standardised factors loadings for the somatic and avoidance factors ranged from .43 - .80 and .60 - .72, respectively. Internal consistency for the responses to the PCS-Helplessness (.92), PCS-Magnification (.82), PCS-Rumination (.94) and overall pain catastrophising (.95) scales were also supported. A good fit to the data was shown for the three-factor structure of the PCS (CMIN/DF = 2.15/61, CFI = .94, RMSEA= .11 (.08-.14), SRMR = .04) when two errors were correlated. Standardised factors loadings ranged from .67-.90, (Helplessness), .89 - .92 (Rumination) and .73 - .85 (Magnification). Conclusion The TSK-11 and PCS can be used to measure axSpA patient’s pain related fear of movement and pain catastrophising, but data support continued examination of their construct validity in larger samples of axSpA patients. One TSK-11 item revealed a border line factor loading (.43) for the somatic factor (“pain lets me know when to stop exercising so that I don’t injure myself”). Psychometrically valid instruments will help examine the role of pain related fear of movement and pain catastrophising on important health related outcomes for axSpA patients including physical function and physical activity behaviour. Disclosure P.C. Rouse: Grants/research support; PhD studentship matched funded by Bath Institute for Rheumatic Diseases (RAG-PR-33-120318). T.A. Ingram: None. M. Standage: None. R. Sengupta: Honoraria; Received honoraria for giving talks from Abbyie, Biogen, UCB, Novartis and Pfizer. Grants/research support; Research grants have been received from UCB, Abbvie, and Novartis.

Assessment and treatment of patients with kinesiophobia: A Delphi consensus

Kinesiophobia is described as pain-related fear of movement and plays a role in the development of chronic musculoskeletal pain. Several approaches have been described in the literature, but there does not seem to be a consensus on the most appropriate way to evaluate and treat patients with kinesiophobia. The aim of this study was to identify clinically relevant assessments and treatments recommended by a consensus of experts. Fourteen experts were identified to participate in a three-round internet-based Delphi study. Participants were asked to propose assessments and treatments (round 1), to grade each proposal on a Likert scale of 9 (round 2), and to reassess their level of agreement (round 3). The consensus was defined with 75% agreement. Five methods of assessment and six treatment approaches reached a consensus. The TAMPA scale reached the top position as an assessment of kinesiophobia. Graded exposure to movement, cognitive and behavioral therapy, and pain neuroscience education were the highest-rated interventions. These results provide the first expert consensus on preferred assessments and treatments for patients with kinesiophobia and correspond with the evidence base in the literature.

Kinesiophobia Predicts Physical Function and Physical Activity Levels in Chronic Pain-Free Older Adults.

Advanced aging is associated with a general decline in physical function and physical activity. The current evidence suggests that pain-related fear of movement (i.e., kinesiophobia) is increased in the general older adult population and impacts physical activity levels in patients with chronic pain. However, whether kinesiophobia could impact physical activity and function in relatively healthy, chronic pain-free older adults remain unclear. Thus, the purpose of this study was to examine whether fear of movement due to pain predicted self-reported and objective levels of physical function and physical activity in healthy older adults without chronic pain. Fifty-two older adults were enrolled in this study. The participants completed the International Physical Activity Questionnaire (IPAQ) and wore an accelerometer on the hip for 7 days to measure physical activity. Measures of sedentary time, light physical activity, and moderate to vigorous physical activity were obtained from the accelerometer. Measures of physical function included the Physical Functioning subscale of the Short Form-36, Short Physical Performance Battery (SPPB), the 30-s Chair Stand test, and a maximal isometric hand-grip. The Tampa Scale of Kinesiophobia (TSK) was used to measure fear of movement or re-injury associated with pain. Potential covariates included self-reported activity-related pain and demographics. Hierarchical linear regressions were conducted to determine the relationship of kinesiophobia with levels of physical activity and physical function while controlling for activity-related pain and demographics. TSK scores did not predict self-reported physical activity on the IPAQ. However, TSK scores predicted self-reported physical function (Beta = −0.291, p = 0.015), 30-s Chair Stand test scores (Beta = −0.447, p = 0.001), measures from the SPPB (Gait speed time: Beta = 0.486, p < 0.001; Chair stand time: Beta = 0.423, p = 0.003), percentage of time spent in sedentary time (Beta = 0.420, p = 0.002) and light physical activity (Beta = −0.350, p = 0.008), and moderate to vigorous physical activity (Beta = −0.271, p = 0.044), even after controlling for significant covariates. These results suggest that greater pain-related fear of movement/re-injury is associated with lower levels of light and moderate to vigorous physical activity, greater sedentary behavior, and worse physical function in healthy, chronic pain-free older adults. These findings elucidate the potential negative impact of kinesiophobia in older adults who don't report chronic pain.

Behavior Modification Techniques on Patients with Chronic Pain in the Context of COVID-19 Telerehabilitation: An Umbrella Review.

The aim of this systematic review (SR) of SRs was to assess the effectiveness of telerehabilitation based on behavior modification techniques (t-BMT) in patients with chronic musculoskeletal pain. We searched in PubMed, PEDro, Web of Science, CINAHL, PsycINFO, and Google Scholar (January 2022). The outcome measures were pain intensity, disability, psychological distress, pain-related fear of movement, disease impact, depressive symptoms, anxiety symptoms, and physical function. This review was previously registered on the international prospective register of systematic reviews PROSPERO (CRD42021262192). Methodological quality was analyzed using the AMSTAR and ROBIS scales, and the strength of evidence was established according to the Physical Activity Guidelines Advisory Committee grading criteria. Four SRs with and without meta-analyses covering 25 trials and involving 4593 patients were included. Of the three SRs that assessed pain intensity, two reported a significant decrease compared to usual care. Contradictory results were also found in the management of psychological distress, and of depressive and anxiety symptoms. However, two reviews found that t-BMT has significant effects on disability, and one review found that t-BMT seems to be effective for improving pain-related fear of movement and disease impact. Finally, one review found that t-BMT does not seem to be an effective modality to improve physical function. The quality of evidence was limited for all outcomes assessed. The results obtained showed that t-BMT was effective in improving disability, disease impact, and pain-related fear of movement, but it was not effective in improving physical function in patients with chronic pain. Mixed evidence was found for pain intensity, psychological distress, and depressive and anxiety symptoms, with a limited quality of evidence.

A group-based chronic pain intervention using the Unlearn Your Pain method: A retrospective one-arm cohort study

LAY SUMMARY Chronic pain is a frequent occurrence in military and Veteran populations. This study examined whether a group-based chronic pain treatment using the Unlearn Your Pain method was effective in reducing chronic pain in 21 military and Veteran participants. Participants completed measures of pain before and after engaging in the treatment, and results showed participants experienced large reductions in total pain and pain-related catastrophizing and moderate reductions in pain-related disability and pain-related fear of movement after completing the treatment. A smaller group of the participants completed the measures again eight weeks after completing treatment, and the size of their improvements was even greater. This study offers preliminary support for the use of the Unlearn Your Pain method as offered in a group format to military and Veteran populations. Further study is warranted.

Cognitive, emotional, and somatosensory behavior in professional dancers with acute and chronic pain.

Dance has been linked in a complex manner to pain and the physical and psychological peculiarities of this discipline could influence pain perception and chronicity of pain. To determine the differences in cognitive, emotional, and somatosensory symptoms between dancers with acute versus chronic pain. A cross-sectional study of professional dancers with pain. Higher conservatory of dance. Thirty-four professional dancers experiencing pain were included. The cohort was divided into two subgroups: those with acute pain (<3months duration) and those with chronic pain (>3months duration). Not applicable. Pain intensity (as measured by the visual analogue scale or VAS), pressure pain threshold (PPT), Pain Catastrophizing Scale (PCS), pain-related fear of movement (Tampa Scale of Kinesiophobia [TSK-11]), fear avoidance beliefs (Fear-Avoidance Beliefs Questionnaire [FABQ]), self-efficacy (Chronic Pain Self-Efficacy Scale [CPSS]). and chronic pain severity (Chronic Pain Graded Scale [CPGS]). Dancers with chronic pain reported higher levels of pain intensity in daily activities (p < .01; t=3.42; d =1.17) and during exercise/dance (p=.02; t=2.82; d =0.82), as well as lower PPT in lumbar (p=.03; t=3.22; d =1.1) and tibialis regions (p=.01; t=2.51; d =0.86). Dancers with acute pain experienced worse psychological symptoms indicated by the fear of harm subscale of TSK-11 (p=.04; t=-2.08; d =0.72), physical activity subscale of FABQ (p=.03; t=-2.27; d =0.78), and pain management subscale of CPSS (p=.01; t=-2.76; d =0.94) and lower scores for CPGS scale (p=.01; t=2.99; d =0.7 to 1.26). The results showed differences in pain intensity and PPT revealing higher values in dancers with chronic pain. It is possible that the physical and psychological characteristics of dancers, as well as the sociocultural aspects of this discipline, could influence the way in which this population interprets pain.

Strength and physical activity in osteoarthritis: The mediating role of kinesiophobia.

The aim of this study was to investigate the association between muscle strength and physical activity level in people with knee osteoarthritis (OA), and determine whether this association is mediated by pain-related fear of movement (kinesiophobia) and self-reported pain. Cross-sectional data from 37 subjects (age 58.8 ± 8.6 years, 25F/12M, BMI 33.5 ± 6.4 kg/m2 ) with OA of the knee were used. Isometric knee extensor and flexor muscle strength were measured using an isokinetic dynamometer. Physical activity, kinesiophobia, and pain were assessed by self-report using the University of California, Los Angeles activity rating scale, Tampa Scale for Kinesiophobia, and The Knee Injury and Osteoarthritis Outcome Score pain subscale, respectively. The associations between strength measures, physical activity, kinesiophobia, and pain scores, were modeled by performing a parallel multiple mediation analysis and the significance of mediational effects (kinesiophobia and pain) were tested using a bootstrap approach. Lower knee flexion and extension strength were associated with lower physical activity scores and these relationships were mediated by higher kinesiophobia scores (more fear) but not pain scores. Knee extension strength was directly associated with physical activity scores after controlling for kinesiophobia and pain scores. These results suggest that muscle strength can influence physical activity directly and indirectly through fear of movement. Assessing these measures together in this population may help clinicians identify patients that are more likely to avoid physical activities due to not only muscle weakness but also fear of movement.

What General and Pain-associated Psychological Distress Phenotypes Exist Among Patients with Hip and Knee Osteoarthritis?

Psychological distress can negatively influence disability, quality of life, and treatment outcomes for individuals with hip and knee osteoarthritis (OA). Clinical practice guidelines recommend a comprehensive disease management approach to OA that includes the identification, evaluation, and management of psychological distress. However, uncertainty around the best psychological screening and assessment methods, a poor understanding of the heterogeneity of psychological distress in those with OA, and lack of guidance on how to scale treatment have limited the growth of OA care models that effectively address individual psychological needs. (1) Across which general and pain-related psychological distress constructs do individuals seeking conservative care for hip or knee OA report higher scores than the general population of individuals seeking conservative care for musculoskeletal pain conditions? (2) What common psychological phenotypes exist among nonsurgical care-seeking individuals with hip or knee OA? The sample included participants from the Duke Joint Health Program (n = 1239), a comprehensive hip and knee OA care program, and the Optimal Screening for Prediction of Referral and Outcome (OSPRO) cohort studies (n = 871) comprising individuals seeking conservative care for knee, shoulder, low back, or neck pain. At the initial evaluation, patients completed the OSPRO Yellow Flag (OSPRO-YF) Assessment Tool, which assesses 11 general and pain-related psychological distress constructs (depression, anxiety, fear of movement, self-efficacy for managing one's own pain). We used OSPRO-YF scores to compare levels of psychological distress between the cohorts. Cohen's d effect sizes were calculated to determine the magnitude of differences between the groups, with d = 0.20, d = 0.50, and d = 0.80 indicating small, medium, and large effect sizes, respectively. We used a latent class analysis to derive psychological distress phenotypes in people with OA based on the 11 OSPRO-YF psychological distress indicators. Psychological distress phenotypes are characterized by specific mood, belief, and behavioral factors that differentiate subgroups within a population. Phenotyping can help providers develop scalable treatment pathways that are better tailored to the common needs of patients. Patients with OA demonstrated higher levels of general and pain-related psychological distress across all psychological constructs except for trait anxiety (that is, anxiety level as a personal characteristic rather than as a response to a stressful situation, like surgery) with small-to-moderate effect sizes. Characteristics with the largest effect sizes in the OA and overall OSPRO cohort were (Cohen's d) general anxiety (-0.66, lower in the OA cohort), pain catastrophizing (the tendency to ruminate over, maginfiy, or feel helpless about a pain experience, 0.47), kinesiophobia (pain-related fear of movement, 0.46), pain self-efficacy (confidence in one's own ability to manage his or her pain, -0.46, lower in the OA cohort), and self-efficacy for rehabilitation (confidence in one's own ability to perform their rehabilitation treatments, -0.44, lower in the OA cohort). The latent class analysis yielded four phenotypes (% sample): high distress (52%, 647 of 1239), low distress (26%, 322 of 1239), low self-efficacy and acceptance (low confidence in managing and willingness to accept pain) (15%, 186 of 1239), and negative pain coping (exhibiting poor pain coping skills) (7%, 84 of 1239). The classification error rate was near zero (2%), and the median of posterior probabilities used to assign subgroup membership was 0.99 (interquartile range 0.98 to 1.00), both indicating excellent model performance. The high-distress group had the lowest mean age (61 ± 11 years) and highest levels of pain intensity (6 ± 2) and disability (HOOS JR: 50 ± 15; KOOS JR: 47 ± 15), whereas the low-distress group had the highest mean age (63 ± 10 years) and lowest levels of pain (4 ± 2) and disability (HOOS JR: 63 ± 15; KOOS JR: 60 ± 12). However, none of these differences met or exceeded anchor-based minimal clinically important difference thresholds. General and pain-related psychological distress are common among individuals seeking comprehensive care for hip or knee OA. Predominant existing OA care models that focus on biomedical interventions, such as corticosteroid injection or joint replacement that are designed to directly address underlying joint pathology and inflammation, may be inadequate to fully meet the care-related needs of many patients with OA due to their underlying psychological distress. We believe this because biomedical interventions do not often address psychological characteristics, which are known to influence OA-related pain and disability independent of joint pathology. Healthcare providers can develop new comprehensive hip and knee OA treatment pathways tailored to these phenotypes where services such as pain coping skills training, relaxation training, and psychological therapies are delivered to patients who exhibit phenotypes characterized by high distress or negative pain coping. Future studies should evaluate whether tailoring treatment to specific psychological phenotypes yields better clinical outcomes than nontailored treatments, or treatments that have a more biomedical focus. Level III, diagnostic study.

Fear of movement is associated with corticomotor depression in response to acute experimental muscle pain.

Acute musculoskeletal pain is associated with reductions in corticomotor output that persists even after pain resolves. Factors that contribute to corticomotor depression following acute pain are unknown. This study examined whether psychological factors, including pain catastrophising, kinesiophobia, and implicit theories of pain, were associated with corticomotor depression following acute experimental muscle pain. Forty-two healthy individuals participated. Participants completed three questionnaires: Pain Catastrophising Scale, Tampa Scale of Kinesiophobia, and Implicit Theories of Pain Scale. Acute pain was induced into the right extensor carpi radialis brevis (ECRB) muscle by injection of hypertonic saline. Corticomotor depression was assessed as a reduction in motor-evoked potentials measured from ECRB muscle in response to transcranial magnetic stimulation before, immediately after, and at 10, 20, and 30min following pain resolution. Corticomotor depression was present at each time point relative to baseline (p < 0.001). Higher levels of kinesiophobia were associated with less corticomotor depression 10-min post pain resolution (r = 0.32, p = 0.03), but not at any other time point (p > 0.11). When corticomotor depression was compared between individuals with 'high' and 'low' kinesiophobia, a similar relationship was observed: Individuals with high compared to low kinesiophobia displayed less corticomotor depression immediately after (p = 0.02) and 10min post pain (p = 0.02), but not at 20 or 30min (p = 0.05 for both). No relationship was observed with any other psychological variable (p > 0.15). These data provide preliminary support for a relationship between pain-related fear of movement and corticomotor depression in response to acute pain. These findings may have implications for clinical musculoskeletal pain disorders.

Role of telerehabilitation in musculoskeletal conditions during COVID-19 pandemic

Sir, The COVID-19 pandemic has led to unprecedented challenges and dilemmas for physiotherapists in relation to physical exercise procedures, continuation of education, and research around the world. The global coronavirus is reminding us the importance of telehealth to deliver rehabilitation services. Implementing telehealth proactively rather than reactively is more likely to generate greater benefits in the long term and help with the everyday (and emergency) challenges in health care.[1] Several states in India have adopted safety and social distancing measures to prevent infection and to further minimize the risk of community transmission through manual contact. Telerehabilitation [Figure 1] is the common term utilized by the physiotherapist internationally for telehealth applications. Telephysiotherapy is the technology used for virtual visit consultations and protocols, which makes use of information and communication to facilitate rehabilitation of patients who are confined in their homes. It is an ultimate tool to provide high-quality personalized musculoskeletal physiotherapy practice in the society and an effective way to reduce crowding of patients and accompanying persons in clinics/hospitals at this crucial time of COVID pandemic.Figure 1: Telerehabilitation at workDespite the significant benefits, a number of challenges in the implementation of telephysiotherapy have been identified in developing countries like India such as underdeveloped infrastructure (poor energy and inadequate power supply, network issues, and shortage of multimedia devices), lack of comprehensive training for professionals, ethical issues (professional licensing, liability and malpractice, privacy, confidentiality, culture, environmental stigma, abuse, and quackery), and financial implications (affordability of mobile phones and reimbursement of rendered services). Complex optical image, sensor-based technologies, and virtual reality-based telerehabilitation systems have eroded these barriers in the last decade in developed countries.[2] Knee osteoarthritis causes musculoskeletal pain and disability affects up to one-third of people aged over 60 years. High-quality evidence has suggested that therapeutic exercise to strengthen muscles can significantly reduce pain and improve physical function and the quality of life (Qol). A health-related survey (36-item short questionnaire) to assess Qol recommends physical, psychological, and social domains of health. It refers to cognitive factors including coping, self-efficacy, somatization, pain catastrophizing, and helplessness and behavioral factors include kinesiophobia (pain related fear of movement) and pain-related fear avoidance.[3] Moderate quality of intervention and positive impact on health outcomes and satisfaction noted in musculoskeletal conditions in a systematic review of telehealth video conferencing physiotherapy.[4] University of Queensland (Australia) and the University of Sherbrooke (Canada) practiced physiotherapy, occupational therapy and speech therapy under the supervision of clinical educators at their state art of telerehabilitation clinial. Theory and practical aspects were introduced via teleheath online learning modules for the academic purpose to develop unique skill through hands-on practicum, in which students and clinical educators worked through clinical cases.[5] PhysioDirect, a united kingdom-based telephone-delivered physiotherapy service, has proven equally effective as usual treatment for people with musculoskeletal conditions. Telephysiotherapy is more accessible and affordable and does not require access to a computer or Internet and does not even require skills needed to operate high tech gadgets. It may therefore mitigate the clinical, economical, and social burden in the society and in some ways revolutionize the practice of physiotherapy in future.[6] Physiotherapists have proven their resilience and professional dedication to stand firm with other health-care professionals as a frontline rehabilitative team. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Action observation as a treatment option for fear avoidance behavior in chronic spinal pain

Psychological factors play an essential role in the maintenance of various chronic pain states, with fear avoidance beliefs contributing to significant functional limitation and disability in chronic spinal pain. Fear avoidance behaviors are typically managed with cognitive-behavioral interventions such as graded exposure to feared movements and graded activity programs. However, attempts to make patients with high pain-related fear perform painful actions using graded exposure therapy can be very challenging. These fear avoidance beliefs in individuals with pain are usually acquired through previous pain experiences, observation, and threating verbal input from others that movement is harmful to the spinal structures. Observational learning of fear has been recently demonstrated in several experimental studies, where participants acquired fear of pain after observing the distressed painful expressions of the volunteers performing a painful cold pressor task. The primary purpose of this paper is to propose action observation, a cognitive rehabilitation technique, as one of the treatment options for reducing fear avoidance behavior in chronic spinal pain. Action observation involves the visualization of others performing a movement or an action to influence motor behavior positively and is mainly used in stroke rehabilitation. The paper hypothesizes that the pain-related fear of movement may be reduced through observation of others performing threatening movements successfully without displaying pain or discomfort. Action observation of others successfully executing a strenuous task may break the preexisting cognitive association between movement and pain among patients with high pain-related fear. Other possible mechanisms through which observation may influence pain-related fear could be the activation of mirror neuron systems and subsequent modulation of nociceptive information through the interconnections between the amygdala (one of the brain centers for fear), descending pain modulatory system and higher cortical centers. Few initial studies that investigated the effects of action observation on other outcomes of pain, such as pain severity are described to review the hypothesis. Considering the influence of observational learning on pain-related fear, action observation may be explored as potential adjunctive treatment to reduce fear avoidance behavior in chronic spinal pain.

Predictors of Persistent Neuropathic Pain – A Systematic Review

Background: Characterization of the prognostic variables for persistent neuropathic pain (PNP) remains incomplete despite multiple articles addressing this topic. To provide more insight into the recovery and prognosis of neuropathic pain, high-quality data are required that provide information about the predictors that contribute to the development of PNP. Objective: To determine the methodological quality of studies about predictors for PNP and to summarize findings of predictors found in high-quality studies. Study Design: A systematic review. Setting: VU University Medical Center, Amsterdam, The Netherlands. Methods: Studies were identified by searching the electronic databases PubMed, Embase, and Cochrane Library. Methodological quality of each article was independently assessed by 2 reviewers. Results: Forty-six relevant studies were identified, classified into 4 different neuropathic pain (NP)- syndromes: postherpetic neuralgia (n = 35), radicular pain and sciatica (n = 3), postsurgical pain (n = 6), and other types of NP (n = 2). Seven studies were of high quality. The 3 high-quality studies found for PHN reported male gender, older age, smoking, trauma at the site of lesion, missed antiviral prescriptions, higher acute pain severity, higher rash severity, more neuropathic characteristics, shorter rash duration, and a lower health status as predictors for PNP. For persistence of radicular pain one high-quality study reported negative outcome expectancies, pain-related fear of movement, and passive pain coping as predictors for PNP. Psychological distress, acute pain, breast cancer surgery, higher body mass index, area of secondary hyperalgesia, neuropathic characteristics, hypoesthesia, and hyperesthesia were found to be predictive for postsurgical pain in 3 high-quality studies. Limitations: Some publications may have been missed during literature search. The low-quality of the studies could be the result of an incomplete description of their methods. Conclusions: High-quality studies mainly assessed factors related to disease functions and structures. Due to shortcomings in methodological quality and limited areas of predictor selection, there is a need for high-quality studies focusing on predictor measurement, statistical analysis and the use of a standardized set of predictors. Key words: Neuropathic pain, persistent pain, systematic review, literature search, predictors, quality assessment, ICF-model

The interactions between pain, pain-related fear of movement and productivity.

Employees with physically heavy work have an increased risk of musculoskeletal disorders leading to reduced work ability. To investigate if a high level of musculoskeletal pain or pain-related fear of movement was associated with low productivity among employees with physically heavy work and differing work ability levels. The study was conducted at a Danish production site and employees with physically heavy work in the production line were included in the study. Work ability was assessed with the Work Ability Index (WAI), pain-related fear of movement with the Tampa Scale for Kinesiophobia and productivity and musculoskeletal pain by self-reported measures. Sickness absence records for construction of WAI were obtained from the workplace. There was a 77% response rate with 350 employees included in the final analysis. Among employees with only moderate work ability, there was neither an association between pain and productivity nor between pain-related fear of movement and productivity. For employees with good work ability, higher levels of pain and higher levels of pain-related fear of movement both raised the odds of low productivity significantly. Despite the fact that musculoskeletal pain increases the risk of reduced work ability significantly, musculoskeletal pain and pain-related fear of movement were associated with low productivity only among employees with good work ability.

Pain-related fear of movement and catastrophizing in whiplash-associated disorders.

The main aim of this study was to test whether pain-related fear of movement and catastrophizing were predictors of pain intensity and disability 6 months after a whiplash injury. The mediator role of fear of movement was also explored. A sample of 147 whiplash patients with neck pain for less than 3 months participated in the first assessment, and 123 of them were interviewed again at a 6-month follow-up. Multiple regression analyses were performed. Fear of movement, initial pain intensity and initial disability were independent predictors of disability at the 6-month follow-up. Initial pain intensity and initial pain duration were significant predictors of pain intensity at 6 months. Fear of movement was found not to be a mediator in either of the 2 outcomes at the 6-month follow-up. These findings suggest that interventions designed to reduce the impact of injury severity and pain-related fear of movement after a motor vehicle accident may be relevant for preventing long-lasting symptoms.

Effect of Peer-Based Low Back Pain Information and Reassurance at the Workplace on Sick Leave: A Cluster Randomized Trial

Purpose To evaluate whether information and reassurance about low back pain (LBP) given to employees at the workplace could reduce sick leave. Methods A Cluster randomized controlled trial with 135 work units of about 3,500 public sector employees in two Norwegian municipalities, randomized into two intervention groups; Education and peer support (EPS) (n = 45 units), education and “peer support and access to an outpatient clinic” (EPSOC) (n = 48 units), and a control group (n = 42 units). Both interventions consisted of educational meetings based on a “non-injury model” and a “peer adviser” appointed by colleagues. Employees in the EPSOC group had access to an outpatient clinic for medical examination and further education. The control group received no intervention. The main outcome was sick leave based on municipal records. Secondary outcomes were self-reported pain, pain related fear of movement, coping, and beliefs about LBP from survey data of 1,746 employees (response rate about 50 %). Results EPS reduced sick leave by 7 % and EPSOC reduced sick leave by 4 % during the intervention year, while sick leave in the control group was increased by 7 % during the same period. Overall, Rate Ratios (RR) were statistically significant for EPSOC (RR = .84 (C.I = 0.71–.99) but not EPS (RR = .92 (C.I = 0.78–1.09)) in a mixed Poisson regression analysis. Faulty beliefs about LBP were reduced in both intervention groups. Conclusions Educational meetings, combined with peer support and access to an outpatient clinic, were effective in reducing sick leave in public sector employees.

Physical and Psychosocial Predictors of Functional Trunk Capacity in Older Adults With and Without Low Back Pain

ObjectiveThe purpose of this study was to determine the physical and psychosocial predictors of functional trunk capacity in a group of healthy elderly individuals and a group of elderly patients with chronic low back pain (LBP). MethodsThe study was done in Canada and included 61 community-dwelling elderly individuals (29 patients with nonspecific chronic LBP and 32 healthy participants) who performed maximal trunk endurance and force tasks. Participants completed various psychologic and functional questionnaires. Sequential linear regression analyses were performed with functional capacity results (endurance and force) as dependent variables and questionnaire scores as independent variables. ResultsEndurance time and peak force were significantly lower in patients compared with healthy elderly individuals (all P values < .001), whereas pain-related fear of movement, pain catastrophizing, and depression levels were higher in patients than their healthy counterpart (all P values < .001). After adjusting for physical activity and disability levels (R2 = 33.7%-50.5% in patients; R2 = 0.1%-5.7% in healthy individuals), none of the psychologic questionnaire could explain variations observed in functional capacity in patients (R2 changes, 4.8%-6.7%) and in healthy participants (R2 changes, 5.2%-10.6%). ConclusionPatients showed diminished functional capacity compared with healthy participants. Moreover, physical activity levels represent the most important predictors of functional capacity in elderly patients with LBP.

The role of presurgical expectancies in predicting pain and function one year following total knee arthroplasty

The present study examined the prospective value of response expectancies (ie, pain, sleep) and behavioral outcome expectancies (ie, return to function) in the prediction of pain severity and functional limitations 12months after total knee arthroplasty (TKA). The study sample consisted of 120 individuals (73 women, 47 men) with osteoarthritis of the knee who were scheduled for TKA. Measures of expectancies, pain severity, pain catastrophizing, pain-related fears of movement, and depression were completed prior to surgery. Participants also completed measures of pain severity and functional limitations 12months following surgery. Analyses revealed that behavioral outcome expectancies were stronger predictors of follow-up pain and functional limitations than response expectancies. Consistent with previous research, analyses also revealed that pain catastrophizing, pain-related fear of movement, and depression predicted follow-up pain and function. In a multivariate analysis, only pain catastrophizing contributed significant unique variance to the prediction of follow-up pain and function. Behavioral outcome expectancies partially mediated the relation between catastrophizing and follow-up pain and function. The relation between catastrophizing and follow-up pain severity and functional limitations remained significant even when controlling for behavioral outcome expectancies. The results suggest that interventions designed to specifically target behavioral outcome expectancies and catastrophizing might improve post-surgical outcomes.

Activity Increase Despite Arthritis (AIDA): design of a Phase II randomised controlled trial evaluating an active management booklet for hip and knee osteoarthritis [ISRCTN24554946

BackgroundHip and knee osteoarthritis is a common cause of pain and disability, which can be improved by exercise interventions. However, regular exercise is uncommon in this group because the low physical activity level in the general population is probably reduced even further by pain related fear of movement. The best method of encouraging increased activity in this patient group is not known. A booklet has been developed for patients with hip or knee osteoarthritis. It focuses on changing disadvantageous beliefs and encouraging increased physical activity.Methods/DesignThis paper describes the design of a Phase II randomised controlled trial (RCT) to test the effectiveness of this new booklet for patients with hip and knee osteoarthritis in influencing illness and treatment beliefs, and to assess the feasibility of conducting a larger definitive RCT in terms of health status and exercise behaviour. A computerised search of four general medical practice patients' record databases will identify patients older than 50 years of age who have consulted with hip or knee pain in the previous twelve months. A random sample of 120 will be invited to participate in the RCT comparing the new booklet with a control booklet, and we expect 100 to return final questionnaires. This trial will assess the feasibility of recruitment and randomisation, the suitability of the control intervention and outcome measurement tools, and will provide an estimate of effect size. Outcomes will include beliefs about hip and knee pain, beliefs about exercise, fear avoidance, level of physical activity, health status and health service costs. They will be measured at baseline, one month and three months.DiscussionWe discuss the merits of testing effectiveness in a phase II trial, in terms of intermediate outcome measures, whilst testing the processes for a larger definitive trial. We also discuss the advantages and disadvantages of testing the psychometric properties of the primary outcome measures concurrently with the trial.Trial registrationCurrent Controlled Trials ISRCTN24554946