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Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art
Abstract
In an attempt to explain how and why some individuals with musculoskeletal pain develop a chronic pain syndrome, Lethem et al. (Lethem J, Slade PD, Troup JDG, Bentley G. Outline of fear-avoidance model of exaggerated pain perceptions. Behav Res Ther 1983; 21: 401-408).ntroduced a so-called 'fear-avoidance' model. The central concept of their model is fear of pain. 'Confrontation' and 'avoidance' are postulated as the two extreme responses to this fear, of which the former leads to the reduction of fear over time. The latter, however, leads to the maintenance or exacerbation of fear, possibly generating a phobic state. In the last decade, an increasing number of investigations have corroborated and refined the fear-avoidance model. The aim of this paper is to review the existing evidence for the mediating role of pain-related fear, and its immediate and long-term consequences in the initiation and maintenance of chronic pain disability. We first highlight possible precursors of pain-related fear including the role negative appraisal of internal and external stimuli, negative affectivity and anxiety sensitivity may play. Subsequently, a number of fear-related processes will be discussed including escape and avoidance behaviors resulting in poor behavioral performance, hypervigilance to internal and external illness information, muscular reactivity, and physical disuse in terms of deconditioning and guarded movement. We also review the available assessment methods for the quantification of pain-related fear and avoidance. Finally, we discuss the implications of the recent findings for the prevention and treatment of chronic musculoskeletal pain. Although there are still a number of unresolved issues which merit future research attention, pain-related fear and avoidance appear to be an essential feature of the development of a chronic problem for a substantial number of patients with musculoskeletal pain.
... "Cognitive factors of pain," which are impressions and perceptions of pain, contribute to the chronicity of pain 12) . Cognitive factors of pain include (but are not limited to) coping style, psychological distress, fear of movement, functional self-efficacy, pain control, depression, and catastrophizing. ...
... Cognitive factors of pain include (but are not limited to) coping style, psychological distress, fear of movement, functional self-efficacy, pain control, depression, and catastrophizing. The fear-avoidance model suggests that chronic pain can arise through two different paths based on the perception of pain experience 12) . ...
... The median WFun scores were 14 (IQR: 9-18) and 13 (IQR:[8][9][10][11][12][13][14][15][16] for men and women, respectively, showing no significant gender difference in presenteeism status. Regarding the status of cognitive factors of pain, the median PCS scores for pain catastrophizing were 19 (IQR: 10-26) and 20 (IQR: 12-27) for men and women, respectively, showing no significant difference by gender. ...
Presenteeism has been noted to be associated with cognitive factors of pain, such as pain catastrophizing (PC) and pain self-efficacy (PS). Pain perception differs by gender, so it is important to consider gender differences when examining the association between cognitive factors of pain and presenteeism. This study aimed to examine the association between presenteeism and cognitive factors of pain, taking gender differences into account. A cross-sectional survey of 305 workers was conducted using a self-administered questionnaire that included items on pain status, PC, PS, and work performance. Multiple logistic regression analysis was used to test whether PC and PS independently influence presenteeism, separately for men and women. Logistic regression analysis showed that PC was extracted in men, and the group with severe PC had higher odds of presenteeism (odds ratio 6.56, 95%confidence interval [CI] 1.83–23.40). Contrarily, PS was extracted in women, with higher odds of presenteeism in the moderate (odds ratio 2.54, 95%CI 1.01–6.39) and low (odds ratio 5.43, 95%CI 1.31–22.50) PS groups than in the high PS. This study showed that the cognitive factors of pain related to presenteeism may differ by gender.
... Several theoretical frameworks have been offered in hopes of explaining the nature of pain catastrophizing. Among them, particularly valuable have been the cognitive-behavioral theory [27,29] and the fear-avoidance theory [30,31] (see Figures 1 and 2). ...
... Several theoretical frameworks have been offered in hopes of explaining the nature of pain catastrophizing. Among them, particularly valuable have been the cognitive-behavioral theory [27,29] and the fear-avoidance theory [30,31] (see Figures 1 and 2). The cognitive-behavioral theory [27] postulates that pain catastrophizing is a dysfunctional cognitive process, marked by selective attention to painful stimuli, interpretation of pain sensations as catastrophic, and maladaptive coping mechanisms. ...
... A robust correlation has been consistently found between high levels of anxiety and depression and frequent exacerbations in pain intensity, as well as greater degree of disability [71]. Similarly, fear of pain that comes with movement, which can commonly be observed in individuals suffering from chronic pain conditions, can lead to avoidance behaviors, and resulting physical deconditioning, lessened quality of life, and ironically even higher levels of pain severity and pain-related distress [30,31]. ...
The perception of pain is strongly influenced by various social, emotional, and cognitive factors. A psychological variable which has consistently been shown to exert its influence on pain is a cognitive process referred to as pain catastrophizing. Numerous studies have found it to be a strong predictor of pain intensity and disability across different clinical populations. It signifies a maladaptive response to pain marked by an exaggerated negative assessment, magnification of symptoms related to pain, and, in general, a tendency to experience marked pain-related worry, as well as experiencing feelings of helplessness when it comes to dealing with pain. Pain catastrophizing has been correlated to many adverse pain-related outcomes, including poor treatment response, unsatisfactory quality of life, and high disability related to both acute and chronic pain. Furthermore, there has been consistent evidence in support of a correlation between pain catastrophizing and mental health disorders, such as anxiety and depression. In this review, we aim to provide a comprehensive overview of the current state of knowledge regarding pain catastrophizing, with special emphasis on its clinical significance, and emerging treatment modalities which target it.
... Common themes of catastrophic thoughts include a fear that the pain may increase in intensity or become unmanageable, and that the pain may be a sign of serious disease or tissue damage (Sullivan et al., 1995(Sullivan et al., , 2001. According to the influential fear-avoidance model of pain (Vlaeyen & Linton, 2000), pain catastrophising is the main driver of avoidance. In this framework, catastrophizing maintains pain-related avoidance behavior over time, further exacerbating functional impairment, disuse and depression. ...
... Pain-related avoidance behavior, i.e., the avoidance of situations and activities that give rise to pain or pain-related distress, is widely believed to increase the risk of pain chronicity (McCracken & Morley, 2014;Vlaeyen & Linton, 2000). Pain-related avoidance behavior has been found to predict pain intensity, hypervigilance towards bodily symptoms, disability and psychological distress, as well as pain catastrophizing (Geisser, Haig, & Theisen, 2000;Goubert, Crombez, Eccleston, & Devulder, 2004;Prkachin, Schultz, & Hughes, 2007). ...
... In the context of chronic pain, the effort of avoiding pain paradoxically increases subjective pain experience (Berntzen & Götestam, 1987). As mentioned above, according to the fear-avoidance model of pain (Vlaeyen & Linton, 2000), pain catastrophizing is the hypothesised main driver of avoidance, as the tendency to avoid and escape the perceived threat are among the main features of fear and anxiety. However, potentially, there could also be other drivers of avoidance. ...
Fibromyalgia is a chronic pain condition associated with substantial suffering and societal costs. Traditional cognitive behavior therapy (T-CBT) is the most evaluated psychological treatment, but exposure therapy (Exp-CBT) has shown promise with a pronounced focus on the reduction of pain-related avoidance behaviors. In a recent randomized controlled trial (N = 274), we found that Exp-CBT was not superior to T-CBT (d = -0.10) in reducing overall fibromyalgia severity. This study investigated pain-related avoidance behaviors, pain catastrophizing, hypervigilance, pacing, overdoing and physical activity as potential mediators of the treatment effect. Mediation analyses were based on parallel process growth models fitted on 11 weekly measurement points, and week-by-week time-lagged effects were tested using random intercepts cross-lagged panel models. Results indicated that a reduction in avoidance behaviors, pain catastrophizing, and hypervigilance were significant mediators of change in both treatments. An increase in pacing and a reduction in overdoing were significant mediators in T-CBT only. Physical activity was not a mediator. In the time-lagged analyses, an unequivocal effect on subsequent fibromyalgia severity was seen of avoidance and catastrophizing in Exp-CBT, and of overdoing in T-CBT. Exposure-based and traditional CBT for fibromyalgia appear to share common treatment mediators, namely pain-related avoidance behavior, catastrophizing and hypervigilance.
... Tampa Scale for Kinesiophobia The Tampa Scale for Kinesiophobia (TSK) was developed to measure the fear of movement/(re) injury [22], although its publication occurred later. After obtaining the necessary permissions, Vlaeyen et al. [23] published the scale. The scale comprises 17 items on a 4-point Likert scale ranging from 1 (Strongly Disagree) to 4 (Strongly Agree), where higher scores indicate a higher level of fear of movement/(re)injury. ...
... Research has shown that an increase in kinesiophobia levels correlates with a heightened risk of pain and injury [3]. The pain fear-avoidance model [23,46] suggests that catastrophizing thoughts about pain and the fear of its recurrence lead to avoidance behaviors, an overreaction to potential threats, and ultimately, movement avoidance [46,47]. Individuals who engage in avoidance behaviors are more likely to suffer from chronic musculoskeletal pain after an injury [46]. ...
Background and Study Aim. Since athletes tend to be addicted to exercise, they are at a higher risk of experiencing sports injuries compared to others. Exercise addiction and kinesiophobia, which is the fear of (re)injury and movement after an injury, are distinct but related concepts for athletes. It has been stated that mindfulness helps individuals to diminish their kinesiophobia. However, little is known about the relationship between exercise addiction, kinesiophobia, and mindfulness among athletes. Therefore, the aim of the study was to investigate kinesiophobia, exercise addiction, and mindfulness among athletes and to examine the effect of certain variables on these three concepts. Material and Methods. The sample of the study consisted of 313 athletes over the age of 18. Participants were included in the study on a voluntary basis, using the convenience sampling method. Study data were collected with the 'Demographic Form', the 'Tampa Scale for Kinesiophobia', and the 'Exercise Addiction Scale'. Results. The study discovered that national athletes exhibited statistically higher levels of exercise addiction compared to non-national athletes. Similarly, athletes suffering from chronic pain showed higher exercise addiction scores than those without chronic pain. Furthermore, athletes who had sustained sports injuries demonstrated higher exercise addiction levels compared to those who had not. It was also determined that athletes with pain or movement limitations due to sports injuries exhibited increased levels of kinesiophobia compared to those without such limitations. In addition, athletes with chronic pain reported higher levels of kinesiophobia compared to their counterparts without chronic pain. Female athletes were found to have higher levels of mindful awareness compared to male athletes. Additionally, when analyzing the relationship between these three parameters, a negative correlation was observed between kinesiophobia and mindfulness among athletes. Conclusions. While kinesiophobia and exercise addiction are not directly related, there is a negative relationship between kinesiophobia and mindfulness. Furthermore, chronic pain and limitations in movement after a sports injury are identified as risk factors for kinesiophobia. Additionally, being a national athlete, experiencing chronic pain, and sustaining sports injuries are considered risk factors for exercise addiction.
... To reduce the likelihood of spurious findings at the derivation stage of the CPRs, the potential variables were selected according to a sound theoretical rationale using well-known theoretical models, namely the neuromuscular spine instability model [45,46], the fear-avoidance model of pain [47] and the common-sense model of illness [48,49], the latter being used to predict treatment adherence [50]. They were classified as Class-A, B and C variables, depending on their relationship with the theoretical background (or potential mechanisms of benefit) of the LSEP. ...
... The LIG showed a greater decrease in their fears and beliefs about physical activity (FABQ-AP) and in pain catastrophizing (PCS) than the SIG. This supports the idea that LSEP allows for very gradual exposure to activity, beginning with motor control exercises, that is conducive to reducing pain and movement-related fears, as proposed by the fear-avoidance model [47] and as demonstrated for different exercise programs [78][79][80][81]. ...
Background
Little is known about why patients with low back pain (LBP) respond differently to treatment, and more specifically, to a lumbar stabilization exercise program. As a first step toward answering this question, the present study evaluates how subgroups of patients who demonstrate large and small clinical improvements differ in terms of physical and psychological changes during treatment.
Methods
Participants (n = 110) performed the exercise program (clinical sessions and home exercises) over eight weeks, with 100 retained at six-month follow-up. Physical measures (lumbar segmental instability, motor control impairments, range of motion, trunk muscle endurance and physical performance tests) were collected twice (baseline, end of treatment), while psychological measures (fear-avoidance beliefs, pain catastrophizing, psychological distress, illness perceptions, outcome expectations) were collected at four time points (baseline, mid-treatment, end of treatment, follow-up). The participants were divided into three subgroups (large, moderate and small clinical improvements) based on the change of perceived disability scores. ANOVA for repeated measure compared well-contrasted subgroups (large vs. small improvement) at different times to test for SUBGROUP × TIME interactions.
Results
Statistically significant interactions were observed for several physical and psychological measures. In all these interactions, the large- and small-improvement subgroups were equivalent at baseline, but the large-improvement subgroup showed more improvements over time compared to the small-improvement subgroup. For psychological measures only (fear-avoidance beliefs, pain catastrophizing, illness perceptions), between-group differences reached moderate to strong effect sizes, at the end of treatment and follow-up.
Conclusions
The large-improvement subgroup showed more improvement than the small-improvement subgroup with regard to physical factors typically targeted by this specific exercise program as well as for psychological factors that are known to influence clinical outcomes.
... Although the rate of UI is high in athletes with more than eight years of experience, women lacked knowledge about this issue and the treatment options. In addition, it was found that the prevalence of UI decreased to 57% in female athletes who had sufficient knowledge about UI (26). Consistent with these results (13,26), we observed that the level of knowledge about incontinence of incontinent women who sought healthcare was higher than the level of those who did not, but the level of knowledge about pelvic floor were similar in both groups. ...
... In addition, it was found that the prevalence of UI decreased to 57% in female athletes who had sufficient knowledge about UI (26). Consistent with these results (13,26), we observed that the level of knowledge about incontinence of incontinent women who sought healthcare was higher than the level of those who did not, but the level of knowledge about pelvic floor were similar in both groups. It is very important to underline that having information about incontinence contributes positively to the health care seeking and that information such as pelvic floor function, dysfunction, risk factors for PFD and treatment options should be incorporated into an education program. ...
Aim: Healthcare seeking by women with urinary incontinence is affected by many factors. However, the effect of pelvic floor awareness and knowledge on seeking health care is not clear. We aimed to investigate the relationship between pelvic floor awareness, urinary incontinence (UI) and pelvic floor knowledge levels and healthcare seeking in women with incontinence. Methods: A total of 178 women, 96 incontinent and 82 continent, were included in the study. The presence of UI was evaluated with Incontinence Questionnaires (3IQ), incontinence knowledge level with the Prolapse and Incontinence Knowledge Questionnaire (PIKQ-UI), and pelvic floor knowledge with the Pelvic Floor Health Knowledge Quiz (PFHKQ). Pelvic floor awareness and treatment seeking were measured with open-ended questions compiled from the literature. The Mann Whitney U, Chi-square and Kruskal Wallis tests were used. A value of p<0.05 was considered statistically significant. Results: There were significant differences between the PIKQ-UI scores of incontinent women who answered yes or no to questions about pelvic floor awareness (p<.05) and seeking health care (p=0.039). The PIKQ-UI scores of incontinent women were higher than those of continent women (p=0.033). Incontinent and continent women had similar PFHKQ scores (p>0.05). A difference was observed in the purpose of seeking information about the pelvic floor between women with and without incontinence (p=0.002). Conclusions: The knowledge level of incontinent women with pelvic floor awareness and who seek health care was higher than that of incontinent women without pelvic floor awareness and who do not seek health care. Pelvic floor awareness in incontinent women may contribute to healthcare seeking and increase the level of knowledge about incontinence and pelvic floor.
... Research has shown that extreme fear of pain is associated with being less physically active (22,23), having limited range of motion (24,25), having greater physical disability (26) and developing strategies for adopting alternative movements (27). Behaviours associated with psychological distress, activity disruption and activity avoidance are essential components of pain-related disability (28). ...
Objective
The purpose of this research was to design and psychometrically validate a new instrument (the Biobehavioural Pain and Movement Questionnaire/BioPMovQ), which assesses the relationship between pain and various factors related to motor behaviour from a biobehavioural perspective.
Methods
A mixed-method design combining a qualitative study with an observational and cross-sectional study was employed to develop (content validity) and psychometrically validate (construct validity, reliability and concurrent/discriminant validity) a new instrument. A total of 200 patients with chronic musculoskeletal pain were recruited.
Results
According to the exploratory factor analysis, the final version of the BioPMovQ consists of 16 items distributed across 4 subscales (1, disability, 2, self-efficacy for physical activity; 3, movement avoidance behaviours; and 4, self-perceived functional ability), all with an eigen value greater than 1, explaining 55.79% of the variance. The BioPMovQ showed high internal consistency (Cronbach’s α = 0.82; McDonald’s ω = 0.83). The intraclass correlation coefficient was 0.86 (95% confidence interval 0.76 to 0.91), which was considered to demonstrate excellent test–retest reliability. The standard error of measurement and minimal detectable change were 3.43 and 8.04 points, respectively. No floor or ceiling effects were identified. There was a positive, significant and moderate magnitude correlation with the Graded Chronic Pain Scale (r = 0.54), kinesiophobia (r = 0.60), pain catastrophising (r = 0.44) and chronic pain self-efficacy (r = −0.31).
Conclusion
The BioPMovQ showed good psychometric properties. Based on the findings of this study, the BioPMovQ can be used in research and clinical practice to assess patients with chronic musculoskeletal pain.
... Importantly, respondents are often likely unaware of the relationships between these constructs and their own perceived activity limitations and participation restrictions, and certainly may not attribute them directly to their pain. One established model with strong face validity is the fear-avoidance model [69][70][71][72]. When asking a respondent with established pain-related fear-avoidance to consider the origin of their perceived reluctance to perform an ADL such as walking or lifting, they may not attribute their limitations directly to pain. ...
Background
Disability is an important multifaceted construct. A brief, generic self-reported disability questionnaire that promises a broader and more comparable measure of disability than disease-specific instruments does not currently exist. The aim of this study was to develop and evaluate such a questionnaire: the Universal Disability Index (UDI).
Methods
An online survey was used to collect general population data. Data were randomly divided into training and validation subsets. The dimensionality and structure of eight UDI questionnaire items were evaluated using exploratory factor analysis (EFA, training subset) followed by confirmatory factor analysis (CFA, validation subset). To assess concurrent validity, the UDI summed score from the full dataset was compared to the Groningen Activity Restriction Scale (GARS) and the Graded Chronic Pain Scale (GCPS) disability scores. Internal consistency and discriminant validity were also assessed. Bootstrapping was used to evaluate model stability and generalisability.
Results
403 participants enrolled; 364 completed at least one UDI item. Three single-factor versions of the UDI were assessed (8-item, 7-item, and 6-item). All versions performed well during EFA and CFA (182 cases assigned to each), but none met the RMSEA (Root Mean Square Error of Approximation) criterion (≤ 0.08). All versions of the UDI had high internal consistency (Cronbach’s α > 0.90), were strongly correlated (Pearson’s r > 0.7) with both GARS and GCPS disability scores, indicating concurrent validity, and could accurately discriminate between upper and lower quartiles of these comparators. Confidence intervals of estimates were narrow, suggesting model stability and generalisability.
Conclusions
A brief, generic self-reported disability questionnaire was found to be valid and to possess good psychometric properties. The UDI has a single factor structure and either a 6-item, 7-item or 8-item version can be used to measure disability. For brevity and parsimony, the 6-item UDI is recommended, but further testing of all versions is warranted.
... The TSK was originally developed to measure the fear of movement with respect to low back pain and evidence supports the reliability and validity of the scores in a variety of samples [21]. TSK scores range from 17 to 68, whereas a higher score indicates a higher degree of kinesiophobia, and a score ≥ 37 was considered high [22]. Consistent with prior research [14], we used a modified version for our concussion history group such that items were specific to their most recent concussion. ...
Aim: The relationship between post-concussion kinesiophobia and clinical and functional reaction time (RT) beyond clinical recovery remains to be elucidated. Methods: College-aged participants with (n = 20) and without (n = 20) a concussion history completed patient-reported outcomes, and RT tasks. Kinesiophobia, symptoms and RTs were compared using t-tests. Linear regressions were performed to determine if kinesiophobia predicted RT measures and dual-task cost. Results: The concussion history group reported higher scores (p < 0.01) for all patient-reported outcomes. We observed significant single-task RT differences between groups (p = 0.013) such that those without a concussion history (m = 0.51s ± 0.08) were faster (m = 0.59s ± 0.12). There were no clinical or dual-task RT differences between groups (p > 0.05). Kinesiophobia significantly predicted single-task RT (R2 = 0.22). Discussion: Kinesiophobia should be considered when measuring RT.
... It has evolved to be known as cervicogenic dizziness to reflect the differences between the term's vertigo and dizziness [23,24,74]. Symptoms described with cervical dysfunctions can mirror symptoms associated with 3PD, particularly anxiety, fear avoidance, catastrophizing, kinesiophobia, and depression [75,76]. Breinbauer [77] utilized a test to assess spatial navigation and found a significant difference in the altered navigational network associated with patients diagnosed with 3PD versus non-3PD diagnoses. ...
Persistent dizziness and balance deficits are common, often with unknown etiology. Persistent Postural-Perceptual Dizziness (3PD) is a relatively new diagnosis with symptoms that may include dizziness, unsteadiness, or non-vertiginous dizziness and be persistent the majority of time over a minimum of 90 days. The purpose of this case series was to investigate short-term outcomes of reducing dizziness symptoms using a manual therapy intervention focused on restoring mobility in the fascia using a pragmatically applied biomechanical approach, the Fascial Manipulation® method (FM®), in patients with 3PD. The preliminary prospective case series consisted of twelve (n = 12) patients with persistent complaints of dizziness who received systematic application of manual therapy to improve fascial mobility after previously receiving vestibular rehabilitation. The manual therapy consisted of strategic assessment and palpation based on the model proposed in the FM® Stecco Method. This model utilizes tangential oscillations directed toward the deep fascia at strategic points. Six males (n = 6) and females (n = 6) were included with a mean age of 68.3 ± 19.3 years. The average number of interventions was 4.5 ± 0.5. Nonparametric paired sample t-tests were performed. Significant improvements were observed toward the resolution of symptoms and improved outcomes. The metrics included the Dizziness Handicap Inventory and static and dynamic balance measures. The Dizziness Handicap Inventory scores decreased (i.e., improved) by 43.6 points (z = −3.1 and p = 0.002). The timed up and go scores decreased (i.e., improved) by 3.2 s (z = −2.8 and p = 0.005). The tandem left increased (i.e., improved) by 8.7 s (z = 2.8 and p = 0.005) and the tandem right increased (i.e., improved) by 7.5 s (z = 2.8 and p = 0.005). Four to five manual therapy treatment sessions appear to be effective for short-term improvements in dizziness complaints and balance in those with 3PD. These results should be interpreted with caution as future research using rigorous methods and a control group must be conducted.
... Das Angstvermeidungsverhalten ist bei Rückenschmerzen von besonderer Bedeutung. Vlaeyen & Linton (2000) beschreiben in diesem Zusammenhang das Fear-Avoidance-Modell (siehe Grafik 1). ...
... Models that expand beyond nociception include the gate control and neuromatrix theories of pain [14,15] and the biopsychosocial [16] and sociopsychobiological [17,18] models. While these models incorporate a broader array of factors that influence the experience of pain, treatment approaches have often continued to aim at symptom reduction as in the operant conditioning methods of Fordyce [19], the fear avoidance model of Vlaeyen and Linton [20], the motivational goal-directed approach pioneered by Karoly and Ruehlman [21], and Cognitive Behavioral Therapy. Sturgeon and Zautra [22] championed resilience as the "new paradigm" for the study of pain and considered "three primary classes of resilient outcomes: recovery, sustainability, and growth." ...
Currently available pain assessment scales focus on pain-related symptoms and limitations imposed by pain. Validated assessment tools that measure how pain is regulated by those who live well with pain are missing. This study seeks to fill this gap by describing the development and preliminary validation of the Biobehavior Life Regulation (BLR) scale. The BLR scale assesses engagement, social relatedness, and self-growth in the presence of chronic pain and the unpredictability of chronic pain. Sources for items included survivor strategies, patient experiences, existing scales, and unpredictable pain research. Review for suitability yielded 52 items. Validation measures were identified for engagement, social relatedness, self-growth, and unpredictability of pain. The study sample (n = 202) represented patients treated in the Phoenix VA Health Care System (n = 112) and two community clinics (n = 90). Demographic characteristics included average age of 52.5, heterogeneous in ethnicity and race at the VA, mainly Non-Hispanic White at the community clinics, 14 years of education, and pain duration of 18 years for the VA and 15.4 years for community clinics. Exploratory factor analysis using Oblimin rotation in the VA sample (n = 112) yielded a two-factor solution that accounted for 48.23% of the total variance. Confirmatory factor analysis (CFA) in the same sample showed high correlations among items in Factor 1, indicating redundancy and the need to further reduce items. The final CFA indicated a 2-factor solution with adequate fit to the data. The 2-factor CFA was replicated in Sample 2 from the community clinics ( n = 90) with similarly adequate fit to the data. Factor 1, Pain Regulation, covered 8 items of engagement, social relatedness, and self-growth while Factor 2, Pain Unpredictability, covered 6 items related to the experience of unpredictable pain. Construct validity showed moderate to higher Pearson correlations between BLR subscales and relevant well-established constructs that were consistent across VA and community samples. The BLR scale assesses adaptive regulation strategies in unpredictable pain as a potential tool for evaluating regulation resources and pain unpredictability.
... However, the findings suggest that for pain-related disability, it is the interpretation of painrelated imagery rather than its presence or absence that may be important. This would be consistent with a cognitivebehavioural understanding of pain (Jamani & Clyde, 2008;Vlaeyen & Linton, 2000) and imagery (Hales et al., 2015) where the meaning attributed to the pain would present as a compelling treatment target, offering the opportunity to advance current treatment approaches for chronic pain. Given that there are already well-established imagery rescripting protocols (Chapman et al., 2020;Haan et al., 2020;Leigh et al., 2020;Nilsson et al., 2019;Tolgou et al., 2018), it is important that the utility of this approach is reviewed for potential use for this clinical population. ...
Purpose
Chronic pain is a highly prevalent and distressing condition with limited treatment efficacy. Prior research reports associations between the experience of mental imagery about chronic pain and pain itself, particularly in those with anxiety and depression. However, many aspects of these associations remain unexplored. A better understanding could help improve cognitive-behavioural therapies for chronic pain. This study aimed to describe the prevalence of intrusive pain-related mental imagery in a sample of people with chronic pain, examine the extent to which this imagery explained variation in pain intensity and disability, and examine the association between negative interpretations of imagery and pain.
Method
A cross-sectional online survey was conducted. Participants with chronic pain (n = 151) completed standardised measures of anxiety, depression, health anxiety, general imagery use, and an adapted questionnaire about intrusive pain-related imagery.
Results
Intrusive pain-related imagery was present in 52.3% of the sample. Demographic variables, anxiety, depression, and health anxiety significantly explained 19% (p < .001) of the variation in pain intensity and 20.2% (p < .001) in pain disability. The presence/absence of intrusive pain-related imagery did not significantly explain any additional variance for either outcome. However negative interpretations of imagery explained additional variance in pain disability. Intrusive imagery was interpreted negatively, experienced as moderately distressing, and was associated with higher rates of anxiety, depression and health anxiety.
Conclusions
Experiencing intrusive imagery about pain is common, but its presence or absence appears to have no direct relationship on pain intensity or disability. The relationship is likely to be more complex, warranting further investigation. Negative interpretations of imagery represent a potential treatment target amenable to intervention.
... Furthermore, given the difference in chronicity, we expect larger amplitude of the SEPs for the CLBP relative to the RLBP group. Finally, based on the pivotal role that fear and catastrophizing play in pain chronicity [24], we explore associations between attentionrelated SEPs and pain catastrophizing as well as fear of movement/(re)injury. deformities were not eligible for inclusion. Furthermore, only Dutch speaking participants between the ages of 18 and 45, with a healthy body mass index (BMI � 25), left or righthanded were eligible. ...
Attention has been proposed to play an important role in persisting pain, with excessive attentional processes towards pain information leading to worse pain outcomes and maladaptive behaviors. Nevertheless, research on somatosensory attending during the anticipation of pain-related movements is still scarce. This study investigated if individuals with chronic and recurrent lower back pain compared to pain-free controls, show enhanced attending to somatosensory information in the back while anticipating back-recruiting movements. 43 healthy control, 33 recurrent (RLBP) and 33 chronic low back (CLBP) pain sufferers were asked to perform back-recruiting movements. Before the movement initiation cue, a task-irrelevant tactile stimulus was administered to participants’ lower back to elicit somatosensory evoked potentials (SEPs), used as an index of somatosensory attending. In contrast to our hypothesis, most identified SEP components did not differ across groups. The only exception was the P175 amplitude which was larger for the CLBP group compared to individuals with RLBP and healthy controls. The current study did not find robust evidence of enhanced somatosensory attending to the back in people with persisting lower back pain. The finding that CLBP, but not RLBP individuals, had larger amplitudes to the P175 component, is discussed as possibly reflecting a higher state of emotional arousal in these patients when having to prepare the back-recruiting movements.
... For example, Turner and Jensen (1993) demonstrated that cognitive therapy, relaxation training, and a combination of both reduced the perceived level of pain after psychological intervention. Vlaeyen and Linton (2000) found that CBT can markedly decrease the severity of back pain and enhance the quality of life for patients. A meta-analysis of randomised trials found that psychological interventions achieved positive outcomes in non-cancer back pain, including pain relief and various beneficial effects on health-related quality of life. ...
Czy pacjenci leczeni w oddziale neurochirurgii mogą odnieść korzyści z psychoterapii? Kilka słów o zastosowaniu terapii poznawczo-behawioralnej u pacjentów leczonych z powodu chorób kręgosłupa ORCID iDs 1. Agnieszka Pawełczyk https://orcid.org/0000-0003-1900-0214 2. Maciej Radek https://orcid.org/0000-0003-3544-1482 The present article reviews the existing literature on the application and effectiveness of cognitive-behavioural therapy in a group of patients with spine problems. It encompasses publications describing the use of cognitive-behavioural therapy in the treatment of patients with back pain and spinal cord injuries of various aetiologies, as well as those experiencing disabilities and difficulties in social and emotional functioning. The findings confirm that cognitive-behavioural interventions are effective in reducing the intensity of pain, improving mobility, reducing the duration of professional inactivity, facilitating adaptation to disability, and enhancing overall life satisfaction. They also support the effectiveness of therapeutic interventions in addressing depressive and anxiety disorders among these patients. It appears that both the traditional and newer approaches of cognitive-behavioural therapy offer potential in patients with spine issues and their families and caregivers. However, due to the insufficient number of randomised and controlled studies, high heterogeneity among study groups, and diversity of research protocols, it is not possible to definitive formulate final conclusions or recommendations at this stage. Nevertheless, the literature findings herein support further exploration of cognitive-behavioural therapy among patients experiencing spine problems. Keywords: back pain, cognitive-behavioural therapy, psychotherapy, spinal cord injury, spine disease W licznych badaniach wykazano skuteczność terapii poznawczo-behawioralnej w leczeniu różnych zaburzeń psychicznych. Autorzy omawiają dostępne piśmiennictwo na temat jej zastosowania i skuteczności w grupie pacjentów z dolegliwościami ze strony kręgosłupa. Prezentują publikacje poświęcone wykorzystaniu terapii poznawczo-behawioralnej w leczeniu chorych z dolegliwościami bólowymi kręgosłupa i uszkodzeniami rdzenia kręgowego o różnej etiologii, doświadczających niepełnosprawności oraz trudności w funkcjonowaniu społecznym i emocjonalnym. Wyniki badań potwierdzają skuteczność interwencji poznawczo-behawioralnych w zmniejszaniu nasilenia bólu, poprawianiu sprawności ruchowej, skracaniu czasu nieaktywności zawodowej oraz przystosowaniu do niepełnosprawności i zwiększaniu zadowolenia z życia. Wskazują także na obiecującą skuteczność oddziaływań terapeutycznych w leczeniu zaburzeń depresyjnych i lękowych w analizowanej grupie chorych. Dostępne prace sugerują możliwość efektywnego stosowania technik terapii poznawczo-behawioralnej-w klasycznej formie i w nowszych podejściach-zarówno u osób z dolegliwościami ze strony kręgosłupa, jak i u rodzin i opiekunów. Ze względu na niewystarczającą liczbę badań randomizowanych i kontrolowanych, dużą heterogeniczność i niską liczebność grup oraz różnorodność protokołów badawczych nie można jeszcze sformułować ostatecznych wniosków i rekomendacji. Wyniki niniejszej pracy zachęcają jednak do podejmowania prób stosowania terapii poznawczo-behawioralnej u chorych z dolegliwościami ze strony kręgosłupa-w leczeniu bólu, a także problemów emocjonalnych i behawioralnych. Abstract Abstract Abstract Abstract Streszczenie Agnieszka Pawełczyk, Weronika Lusa, Maciej Radek
... Along with the exercise, thoughts, and expectations about pain are known to alter the experience of pain (7,13,39,46,51). Factors such as pain catastrophizing, anxiety, and kinesiophobia influence endogenous pain modulation (27). ...
Rana P, Robinson ME, Bishop MD. Uncovering the Sweet Spot: The Interplay Between Aerobic Exercise Intensity, Exercise-Induced Hypoalgesia, and Psychological Factors in Young Healthy Subjects. JEPonline 2024;27(2):63-86. The purpose of this study was to identify the extent to which exercise-induced hypoalgesia (EIH) is induced by a specific intensity of aerobic exercise and its association with psychological factors. Twenty healthy subjects were randomly assigned to five separate training sessions. Pain sensitivity (thermal threshold, suprathreshold heat, temporal Summation, and pressure pain threshold) was assessed before and after the intervention. The ANOVA analysis revealed no significant differences in the pain sensitivity based on the various aerobic exercise intensities. Also, the ANCOVA analysis demonstrated that none of the psychological factors examined were found to be associated with the magnitude of Exercise-Induced Hypoalgesia (EIH) when used as a covariate. Aerobic exercise does not elicit a hypoalgesic effect, which is not consistent with the concept of exercise-induced hypoalgesia, regardless of the intensity of aerobic exercise. None of the psychological factors exerted any influence on the magnitude of hypoalgesia experienced after exercise.
... 28,29 To protect themselves from genitopelvic pain and the associated negative emotions (eg, shame, guilt, sadness), perfectionistic mothers could engage in sexual avoidance, which has been associated with higher genitopelvic pain. 30,31 According to the fear-avoidance model, 15 experiencing pain as a threat (catastrophizing) would lead to increased anxiety, fear, and hypervigilance, which have been associated with greater genitopelvic pain 32 Engaging in avoidance behaviors may exacerbate the perception of pain as a threat, reinforcing the fear-avoidance cycle. 33 Avoidance of sexual activity could also contribute to low self-efficacy by depriving mothers of positive sexual experiences and thereby contribute to sexual pain. ...
Background
Genitopelvic pain following childbirth is common and likely to challenge the psychological, relational, and sexual well-being of new mothers. While genitopelvic pain generally decreases during the postpartum period, personal and interpersonal characteristics may explain why genitopelvic pain persists beyond the period of physical recovery in some mothers. Body image concerns, increased stress, and relationship challenges would be particularly salient during pregnancy and the postpartum period, which could put new mothers at greater risk of sexual difficulties. Also, mothers may display a negative appraisal regarding genitopelvic pain and doubt their ability to cope with it, which may contribute to the pain.
Aim
The current study aimed to examine the role of perfectionism, body image concerns, and perceived intimacy in the occurrence and change in genitopelvic pain in new mothers in postpartum.
Methods
A total of 211 new mothers and their partners were recruited for a larger prospective dyadic study on the transition to parenthood.
Outcomes
Mothers completed a single item assessing genitopelvic pain, in addition to brief validated questionnaires measuring perfectionism, body image concerns, and perceived couple intimacy during pregnancy and at 4, 8, and 12 months postpartum.
Results
Five multilevel modeling analyses revealed that adaptive perfectionism, maladaptive perfectionism, and body image concerns were associated with a higher occurrence of genitopelvic pain from 4 to 12 months postpartum. Mothers’ and partners’ perceived intimacy was not significantly related to new mothers’ genitopelvic pain. None of the predictors modified the trajectory of genitopelvic pain over time.
Clinical Implications
Raising awareness among health care professionals regarding the role of perfectionism and body image concerns in genitopelvic pain may help them identify new mothers at risk of chronic genitopelvic pain, while offering a new avenue of intervention.
Strengths and Limitations
There has been little research examining the role of perfectionism, body image concerns, and intimacy in postpartum genitopelvic pain. Based on a longitudinal prospective approach, this study identified perfectionism and body image concerns as significant predictors of postpartum genitopelvic pain. However, prepregnancy genitopelvic pain, genitopelvic pain intensity, and sexual distress were not measured.
Conclusion
Adaptive and maladaptive perfectionism and body image concerns are associated with new mothers’ genitopelvic pain up to 12 months postpartum.
... Avoidance can then contribute to three adverse states (physical disuse, disability, and depression), which exacerbates the experience of pain, forming a vicious cycle that perpetuates kinesiophobia and functional disuse. An updated model of kinesiophobia by Vlaeyen and Linton (2000) emphasizes that negative affective response, such as anxiety (Lopez-de-Uralde-Villanueva et al., 2017), can influence catastrophic thinking and prompt its occurrence (Serrano-Hernanz et al., 2023). Therefore, if individuals have lower levels of anxiety and other negative emotions after experiencing pain, they are less likely to develop catastrophic thinking and, consequently, kinesiophobia. ...
... NSLBP is multifactorial, with physical, psychological, cognitive, behavioural, lifestyle, and societal conditions all known to contribute to the disorder [2,5]. One proposed contributing factor is related to movement alterations in the spine and pelvis, associated with movement-related fear [5], loss of function [6], physical deconditioning [7], and subsequent disability [8]. The cornerstone of NSLBP management endorsed by clinical guidelines is therefore focused on disrupting this mechanism through education, self-management, and exercise customised to individual needs and capabilities [9,10]. ...
Inertial measurement units (IMUs) offer a portable and quantitative solution for clinical movement analysis. However, their application in non-specific low back pain (NSLBP) remains underexplored. This study compared the spine and pelvis kinematics obtained from IMUs between individuals with and without NSLBP and across clinical subgroups of NSLBP. A total of 81 participants with NSLBP with flexion (FP; n = 38) and extension (EP; n = 43) motor control impairment and 26 controls (No-NSLBP) completed 10 repetitions of spine movements (flexion, extension, lateral flexion). IMUs were placed on the sacrum, fourth and second lumbar vertebrae, and seventh cervical vertebra to measure inclination at the pelvis, lower (LLx) and upper (ULx) lumbar spine, and lower cervical spine (LCx), respectively. At each location, the range of movement (ROM) was quantified as the range of IMU orientation in the primary plane of movement. The ROM was compared between NSLBP and No-NSLBP using unpaired t-tests and across FP-NSLBP, EP-NSLBP, and No-NSLBP subgroups using one-way ANOVA. Individuals with NSLBP exhibited a smaller ROM at the ULx (p = 0.005), LLx (p = 0.003) and LCx (p = 0.01) during forward flexion, smaller ROM at the LLx during extension (p = 0.03), and a smaller ROM at the pelvis during lateral flexion (p = 0.003). Those in the EP-NSLBP group had smaller ROM than those in the No-NSLBP group at LLx during forward flexion (Bonferroni-corrected p = 0.005), extension (p = 0.013), and lateral flexion (p = 0.038), and a smaller ROM at the pelvis during lateral flexion (p = 0.005). Those in the FP-NSLBP subgroup had smaller ROM than those in the No-NSLBP group at the ULx during forward flexion (p = 0.024). IMUs detected variations in kinematics at the trunk, lumbar spine, and pelvis among individuals with and without NSLBP and across clinical NSLBP subgroups during flexion, extension, and lateral flexion. These findings consistently point to reduced ROM in NSLBP. The identified subgroup differences highlight the potential of IMU for assessing spinal and pelvic kinematics in these clinically verified subgroups of NSLBP.
... As pain encompasses subjective experience, patients with chronic pain often have complex experiences 14 with a confusing combination of somatic distress (physical pain) and mental anguish (psychological pain). For example, the catastrophizing thought the "the pain will get worse" (cognition) before starting housework raises anxiety and fear (emotion), resulting in the patient avoiding doing the housework like before (behavior) and experiencing an aggravation of muscle tension and pain (physical) 15 . However, patients describing these experiences in such a well-distributed format before undergoing CBT is uncommon. ...
Pain experiences are often complex with catastrophic cognitions, emotions, and behaviors. Cognitive behavioral therapists share the work of unraveling these complex experiences with their patients. However, the change process underlying the unraveling of the pain experience have not yet been quantified. We used an interrelationship-focused network model to examine the way an undifferentiated conceptualization between cognition and pain experience changed via group cognitive-behavioral therapy (CBT). Overall, 65 participants were included in the study; they attended the total of 12 weekly group CBT and filled the Short-Form McGill Pain Questionnaire and the pain catastrophizing questionnaire. Before treatment, there were no edges in the partial correlation-based network because of large covariation across items. After treatment, many edges appeared and, particularly strong couplings were found between items within the same subscale. The formative shift from a non-edged pre-treatment network to a mature post-treatment network indicates that patients were able to conceptualize these symbolic constructs better. These results are consistent with the fundamental monitoring process of CBT.
... These individuals often alter their movements and activities to avoid pain, leading to behaviors that exacerbate disability and diminish the quality of life [5]. This adaptation, particularly prevalent in CLBP patients [6], underscores the critical need for adaptable therapeutic strategies that can be effectively implemented beyond the confines of conventional care environments [7]. ...
Chronic Low Back Pain (CLBP) afflicts millions globally, significantly impacting individuals' well-being and imposing economic burdens on healthcare systems. While artificial intelligence (AI) and deep learning offer promising avenues for analyzing pain-related behaviors to improve rehabilitation strategies, current models, including convolutional neural networks (CNNs), recurrent neural networks, and graph-based neural networks, have limitations. These approaches often focus singularly on the temporal dimension or require complex architectures to exploit spatial interrelationships within multivariate time series data. To address these limitations, we introduce L-SFAN, a lightweight CNN architecture incorporating 2D filters designed to meticulously capture the spatial-temporal interplay of data from motion capture and surface electromyography sensors. Our proposed model, enhanced with an oriented global pooling layer and multi-head self-attention mechanism, prioritizes critical features to better understand CLBP and achieves competitive classification accuracy. Experimental results on the EmoPain database demonstrate that our approach not only enhances performance metrics with significantly fewer parameters but also promotes model interpretability, offering valuable insights for clinicians in managing CLBP. This advancement underscores the potential of AI in transforming healthcare practices for chronic conditions like CLBP, providing a sophisticated framework for the nuanced analysis of complex biomedical data.
... Research supports a biopsychosocial model of chronic pain, which argues that pain and its impact are influenced by complex interactions between biological, psychological, and social factors [10]. Depression is one of the psychological factors that has been shown to play an important role in the progression and persistence of chronic pain [11,12]. Approximately 20-25% of individuals with CLBP meet criteria for depression [9,13,14], and depression is significantly associated with higher pain severity, disability, worse recovery, and greater healthcare utilization in individuals with CLBP [15][16][17]. ...
Background
The study aimed to cross-culturally adapt the Patient-Reported Outcomes Measurement Information System Short Form v1.0 - Depression 8a (PROMIS SF v1.0 - Depression 8a) into Thai and evaluate its psychometric properties in individuals with chronic low back pain (CLBP).
Methods
The PROMIS SF v1.0– Depression 8a was translated and cross-culturally adapted into Thai using the Functional Assessment of Chronic Illness Therapy translation methodology. Two hundred and sixty-nine individuals with CLBP completed the Thai version of PROMIS SF v1.0– Depression 8a (T-PROMIS-D-8a) scale and a set of measures assessing validity criterion domains. Structural validity, internal consistency, and test-retest reliability at a 7-day interval of the T-PROMIS-D-8a scale were computed and its construct validity was evaluated by computing correlations with the Thai version of Patient Health Questionnaire-9 (T-PHQ-9), Numeric Rating Scale of pain intensity (T-NRS), and Fear Avoidance Beliefs Questionnaire (T-FABQ).
Results
Data from 269 participants were analyzed. Most participants were women (70%), and the sample had a mean age of 42.5 (SD 16.6) years. The findings supported the unidimensionality, internal consistency (Cronbach’s alpha = 0.94), and test-retest reliability (ICC [2,1] = 0.86) of the T-PROMIS-D-8a. A floor effect was observed for 16% of the sample. Associations with the T-PHQ-9, T-NRS, and T-FABQ supported the construct validity of the T-PROMIS-D-8a.
Conclusions
The T-PROMIS-D-8a was successfully translated and culturally adapted. The findings indicated that the scale is reliable and valid for assessing depression in Thai individuals with CLBP.
... Studies on the fear and movement avoidance model and its influence on persistent pain have shown that the pain experience and associative learning are interrelated and linked to the individual coping process, the intensity of the pain response and behavior 9,10 . Experiences related to the adaptive learning process of pain, together with the misinterpretation that movements lead the individual to feel pain, consequently lead to pain-related fear; thus defensive responses can arise, such as escape behavior, avoidance and hypervigilance 12,13 . A photographic scale assessing avoidance behavior in people with chronic shoulder pain (Avoidance of Daily Activities Photo Scale -ADAP) 14 was recently published. ...
BACKGROUND AND OBJECTIVES
Shoulder pain is a limiting condition that has a major impact on daily activities and work. Knowing which specific activities involving the shoulder are associated with the occurrence of higher levels of pain may be of interest to professionals. The use of images of shoulder movements can be an effective tool to check the presence of pain and fear of movement, break down language and cultural barriers, and facilitate communication between professional and patient. The objectives of this study were: (1) to carry out a descriptive analysis of fear responses and movement avoidance based on passive viewing of images of shoulder movements based on the International Classification of Functioning, Disability and Health (ICF) codes; (2) to check whether there is a correlation between fear responses and movement avoidance with the Shoulder Pain and Disability Index (SPADI).
METHODS
In this cross-sectional observational study, individuals with chronic shoulder pain were recruited. Participants responded to the Shoulder Pain and Disability Index (SPADI) and the TAMPA Scale of Kinesiophobia (TSK) to measure the intensity of shoulder pain and disability, and fear of movement, respectively. Participants viewed 58 movement images based on codes and descriptors from the third chapter of ICF. In addition, they responded to a numerical scale to judge fear of movement and a second numerical scale to judge movement avoidance.
RESULTS
The study included 42 individuals. The activities belonging to the mobility subgroup (chapter 4), which refers to chapter 3 of the ICF, are those that present greater responses of fear and movement avoidance. Multiple regression resulted in a significant model [F(1, 40) = 31.119; p<0.001; R2 = 0.438], when verifying whether fear and movement avoidance responses related to ICF images are associated with SPADI in participants with chronic shoulder pain. The fear response is associated with SPADI (β=0.661; t=5.578; p<0.001), however, the avoidance response did not present a significant result with the scale (β=−0.063; t=-0.160; p=0.874).
CONCLUSION
Movements that refer to mobility seem to be the most feared and avoided by people with chronic shoulder pain. Fear of movement is associated with shoulder disability.
Keywords:
Chronic pain; Fear; Shoulder pain
... Fatigue [32], fear of movement (kinesiophobia) and getting pain or injury because of exercises among HSD/hEDS patients [63] have been suggested for non-adherence to physical exercises among EDS patients. Thus, learning how to adjust and overcome the kinesiophobia [89] might have a critical role among EDS patients with TMD. Therefore, we strongly recommend jaw exercises under supervision for EDS patients to decrease the risk of trauma to the joints, and also to keep the patients motivated. ...
Objective
This study is part of the ODIN‐migraine (Optimization of Diagnostic Instruments in migraine) project. It is a secondary, a priori analysis of previously collected data, and aimed to assess the psychometric properties and factor structure of the Cogniphobia Scale for Headache Disorders (CS‐HD). We aimed to construct a German‐language version and a short version.
Background
Cogniphobia is the fear and avoidance of cognitive exertion, which the patient believes triggers or exacerbates headache. High cogniphobia may worsen the course of a headache disorder.
Methods
The 15‐item CS‐HD was translated into German and back translated in a masked form by a professional translator. Modifications were discussed and carried out in an expert panel. A cross‐sectional online survey including the CS‐HD and further self‐report questionnaires was conducted in a sample of N = 387 persons with migraine (364/387 [94.1%] female, M = 41.0 [SD = 13.0] years, migraine without aura: 152/387 [39.3%], migraine with aura: 85/387 [22.0%], and chronic migraine: 150/387 [38.8%]).
Results
Exploratory factor analysis resulted in two clearly interpretable factors ( interictal and ictal cogniphobia ). Confirmatory factor analysis yielded an acceptable to good model fit ( χ ² (89) = 117.87, p = 0.022, χ ² / df = 1.32, RMSEA = 0.029, SRMR = 0.055, CFI = 0.996, TLI = 0.995). Item response theory‐based analysis resulted in the selection of six items for the short form (CS‐HD‐6). Reliability was acceptable to excellent (interictal cogniphobia subscale: ω = 0.92 [CS‐HD] or ω = 0.77 [CS‐HD‐6]; ictal cogniphobia subscale: ω = 0.77 [CS‐HD] or ω = 0.73 [CS‐HD‐6]). The pattern of correlations with established questionnaires confirmed convergent validity of both the CS‐HD and the CS‐HD‐6.
Conclusion
Both the CS‐HD and the CS‐HD‐6 have good psychometric properties and are suitable for the assessment of cogniphobia in migraine.
Stigma is common in people experiencing chronic pain and there are indications that it may adversely affect pain outcomes. However, to date, there is no systematic review exploring the impact of stigma on chronic pain-related outcomes. This systematic review and meta-analysis aimed to examine the association between stigma and key chronic pain outcomes and differences in stigma between pain conditions. Seven databases were searched for studies reporting a measure of association between stigma and at least one pain outcome in adults with chronic pain. Studies were screened by 2 independent researchers. Nineteen studies met eligibility criteria and data were extracted, quality-assessed, and narratively synthesised and meta-analysed where possible. Meta-analyses of bivariate cross-sectional correlations demonstrated significant positive correlations between stigma and pain intensity, disability, and depression, with small to moderate effects. Data from 2 prospective studies and those only reporting multivariate analyses that were not included in meta-analyses further supported these findings. There was some evidence that individuals who experience pain conditions with less clear pathophysiology may report greater stigma, although more research is needed. The review highlights that there is a growing number of studies on stigma in the pain field showing an adverse association between stigma and chronic pain outcomes.
Pre-operative prediction of post-surgical recovery for patients is vital for clinical decision-making and personalized treatments, especially with lumbar spine surgery, where patients exhibit highly heterogeneous outcomes. Existing predictive tools mainly rely on traditional Patient-Reported Outcome Measures (PROMs), which fail to capture the long-term dynamics of patient conditions before the surgery. Moreover, existing studies focus on predicting a single surgical outcome. However, recovery from spine surgery is multi-dimensional, including multiple distinctive but interrelated outcomes, such as pain interference, physical function, and quality of recovery. In recent years, the emergence of smartphones and wearable devices has presented new opportunities to capture longitudinal and dynamic information regarding patients' conditions outside the hospital. This paper proposes a novel machine learning approach, Multi-Modal Multi-Task Learning (M3TL), using smartphones and wristbands to predict multiple surgical outcomes after lumbar spine surgeries. We formulate the prediction of pain interference, physical function, and quality of recovery as a multi-task learning (MTL) problem. We leverage multi-modal data to capture the static and dynamic characteristics of patients, including (1) traditional features from PROMs and Electronic Health Records (EHR), (2) Ecological Momentary Assessment (EMA) collected from smartphones, and (3) sensing data from wristbands. Moreover, we introduce new features derived from the correlation of EMA and wearable features measured within the same time frame, effectively enhancing predictive performance by capturing the interdependencies between the two data modalities. Our model interpretation uncovers the complementary nature of the different data modalities and their distinctive contributions toward multiple surgical outcomes. Furthermore, through individualized decision analysis, our model identifies personal high risk factors to aid clinical decision making and approach personalized treatments. In a clinical study involving 122 patients undergoing lumbar spine surgery, our M3TL model outperforms a diverse set of baseline methods in predictive performance, demonstrating the value of integrating multi-modal data and learning from multiple surgical outcomes. This work contributes to advancing personalized peri-operative care with accurate pre-operative predictions of multi-dimensional outcomes.
Introduction
Gout management remains suboptimal despite safe and effective urate‐lowering therapy. Self‐monitoring of urate may improve gout management, however, the acceptability of urate self‐monitoring by people with gout is unknown. The aim of this study was to explore the experiences of urate self‐monitoring in people with gout.
Methods
Semistructured interviews were conducted with people taking urate‐lowering therapy (N = 30) in a 12‐month trial of urate self‐monitoring in rural and urban Australia. Interviews covered the experience of monitoring and its effect on gout self‐management. Deidentified transcripts were analysed thematically.
Results
Participants valued the ability to self‐monitor and gain more understanding of urate control compared with the annual monitoring ordered by their doctors. Participants indicated that self‐monitoring at home was easy, convenient and informed gout self‐management behaviours such as dietary modifications, hydration, exercise and medication routines. Many participants self‐monitored to understand urate concentration changes in response to feeling a gout flare was imminent or whether their behaviours, for example, alcohol intake, increased the risk of a gout flare. Urate concentrations were shared with doctors mainly when they were above target to seek management support, and this led to allopurinol dose increases in some cases.
Conclusion
Urate self‐monitoring was viewed by people with gout as convenient and useful for independent management of gout. They believed self‐monitoring achieved better gout control with a less restricted lifestyle. Urate data was shared with doctors at the patient's discretion and helped inform clinical decisions, such as allopurinol dose changes. Further research on implementing urate self‐monitoring in routine care would enable an evaluation of its impact on medication adherence and clinical outcomes, as well as inform gout management guidelines.
Patient or Public Contribution
One person with gout, who was not a participant, was involved in the study design by providing feedback and pilot testing the semistructured interview guide. In response to their feedback, subsequent modifications to the interview guide were made to improve the understandability of the questions from a patient perspective. No additional questions were suggested.
According to the ever-increasing trend of the elderly population in Iran, addressing issues related to this group of the society appears to be of great importance. In this regard, the purpose of the present study was to consider the mediating role of emotional regulation in the relationship between emotional schema and pain perception in the elderly. The statistical population of the current study included all the elderly members of the centers for aging in Shiraz, Iran, among whom 251 (104 male, 147 female) who suffer from pain at least in one area of their body, were selected using convenience sampling. Data were gathered using Leahy's Emotional Schema Scale (LESS), Gratz and Roemer's Difficulties in Emotional Regulation Scale (DERS) as well as the McGill's Pain Questionnaire (MPQ), and were analyzed by Structural Equations Modeling in SPSS-24 and LISREL-10.20 software. The results of Structural Equations Modeling indicated that the extracted model has a good fit with the empirical data. Moreover, results revealed that using limited emotional regulation strategies is able to mediating the relationship between emotional schemas of consensus, rumination, expression and numbness with pain perception in the elderly. Therefore, according to the role that emotional schemas and difficulties in emotional regulation can paly in predicting the pain perception in elderly, paying attention to these factors in preparing education and therapeutic intervention seems crucial.
In the endeavor to advance our understanding of interindividual differences in dealing with chronic pain, numerous motivational theories have been invoked in the past decade. As they focus on relevant, yet different aspects of the dynamic, multilevel processes involved in human voluntary action control, research findings seem fragmented and inconsistent. Here we present Personality Systems Interactions theory as an integrative meta-framework elucidating how different motivational and volitional processes work in concert under varying contextual conditions. PSI theory explains experience and behavior by the relative activation of four cognitive systems that take over different psychological functions during goal pursuit. In this way, it may complement existing content-related explanations of clinical phenomena by introducing a functional, third-person perspective on flexible goal management, pain acceptance and goal maintenance despite pain. In line with emerging evidence on the central role of emotion regulation in chronic pain, PSI theory delineates how the self-regulation of positive and negative affect impacts whether behavior is determined by rigid stimulus-response associations (i.e., habits) or by more abstract motives and values which afford more behavioral flexibility. Along with testable hypotheses, multimodal interventions expected to address intuitive emotion regulation as a central process mediating successful adaptation to chronic pain are discussed.
Objective
To explore the practice of prescribing and implementing early mobilisation and weight-bearing as tolerated after hip fracture surgery in older adults and identify barriers and facilitators to their implementation.
Methods
Semi-structured interviews were conducted with 20 healthcare providers (10 orthopaedic surgeons and 10 physiotherapists) from Saudi Arabian government hospitals. Data were analysed using inductive thematic analysis.
Results
While early mobilisation and weight-bearing as tolerated were viewed as important by most participants, they highlighted barriers to the implementation of these practices. Most participants advocated for mobility within 48 h of surgery, aligning with international guidance; however, the implementation of weight-bearing as tolerated was varied. Some participants stressed the type of surgery undertaken as a key factor in weight-bearing prescription. For others, local protocols or clinician preference was seen as most important, the latter partially influenced by where they were trained. Interdisciplinary collaboration between orthopaedic surgeons and physiotherapists was seen as a crucial part of postoperative care and weight-bearing. Patient and family member buy-in was also noted as a key factor, as fear of further injury can impact a patient’s adherence to weight-bearing prescriptions. Participants noted a lack of standardised postoperative protocols and the need for routine patient audits to better understand current practices and outcomes.
Conclusion
This study contributes to national and global discussions on the prescription of early mobilisation and weight-bearing as tolerated. It highlights the necessity for a harmonised approach, incorporating standardised, evidence-based protocols with patient-specific care, robust healthcare governance and routine audits and monitoring for quality assurance and better patient outcomes.
Background
There is a lack of research on the relationship between pain catastrophizing, kinesiophobia, and physical activity (PA) in people with haemophilia (PWH), and the underlying mechanisms connecting these variables remain unclear.
Aim
The study's aim was to clarify the roles of kinesiophobia and self‐efficacy in the relationship between pain catastrophizing and PA in PWH.
Methods
This cross‐sectional study included adult PWH at the Haemophilia Centre of a Tertiary hospital in Beijing, China. The following questionnaires were used to collect data: the general information, the International Physical Activity Short Questionnaire, the Pain Catastrophizing Scale, the Tampa Scale of Kinesiophobia Scale, and the Exercise Self‐Efficacy Scale.
Results
The study included a total of 187 PWH, including 154 having haemophilia A and 33 having haemophilia B. The median interquartile range of PA was 594 (198, 1554) MET‐min/wk. There were significant differences in PA of patients based on age stage, treatment modality, highest pain score within the last seven days, and presence of haemophilic arthropathy ( p < .05). It was showed that pain catastrophizing could directly predict PA ( p < .001), accounting for 38.13% of the total effect. Pain catastrophizing also had indirect effects on PA through the mediating factors of kinesiophobia or self‐efficacy, and through the chain‐mediating effect of kinesiophobia and self‐efficacy, accounting for 38.40%, 17.07%, and 6.40%, respectively.
Conclusion
The study discovered that PWH have limited PA due to pain catastrophizing. This not only directly affects their activity but also indirectly influences it through kinesiophobia and self‐efficacy.
BACKGROUND: Impairment in both the motor and cognitive aspects of postural control is a critical issue in patients with chronic low back pain (CLBP) who experience high pain anxiety (HPA). OBJECTIVE: This study aimed to compare the effects of cathodal and anodal transcranial direct current stimulation (c-tDCS and a-tDCS) over the dorsolateral prefrontal cortex (DLPFC) on postural control during cognitive postural tasks in CLBP patients with HPA. METHODS: This study included 66 patients randomly assigned to three groups: DLPFC a-tDCS, DLPFC c-tDCS, and sham tDCS. All groups received 20 minutes of tDCS, but the stimulation was gradually turned off in the sham group. Postural stability indices were assessed using the Biodex Balance System. RESULTS: Both the a-tDCS and c-tDCS groups showed a significant reduction in most postural stability indices at static and dynamic levels after the interventions (immediately, 24 hours, and one-week follow-up) during the cognitive postural task (P< 0.01). Additionally, there was a significant improvement in postural balance in the a-tDCS and c-tDCS groups compared to the sham tDCS group (P< 0.01). Furthermore, the a-tDCS group showed significantly greater improvement than the c-tDCS group (P< 0.01). CONCLUSION: Based on the results, both a-tDCS and c-tDCS over the DLPFC had positive effects on postural control during cognitive postural tasks in CLBP patients with HPA.
The present article reviews the existing literature on the application and effectiveness of cognitive-behavioural therapy in a group of patients with spine problems. It encompasses publications describing the use of cognitive-behavioural therapy in the treatment of patients with back pain and spinal cord injuries of various aetiologies, as well as those experiencing disabilities and difficulties in social and emotional functioning. The findings confirm that cognitive-behavioural interventions are effective in reducing the intensity of pain, improving mobility, reducing the duration of professional inactivity, facilitating adaptation to disability, and enhancing overall life satisfaction. They also support the effectiveness of therapeutic interventions in addressing depressive and anxiety disorders among these patients. It appears that both the traditional and newer approaches of cognitive-behavioural therapy offer potential in patients with spine issues and their families and caregivers. However, due to the insufficient number of randomised and controlled studies, high heterogeneity among study groups, and diversity of research protocols, it is not possible to definitive formulate final conclusions or recommendations at this stage. Nevertheless, the literature findings herein support further exploration of cognitive-behavioural therapy among patients experiencing spine problems.
Background
Recent studies have investigated the effect of psychological factors on return to sport (RTS), but none has tested the existence of psychological profiles linked to reinjury anxiety and its links with RTS and reinjury.
Purpose
To assess the effect of different psychological profiles on RTS and reinjury.
Study Design
Cohort study; Level of evidence, 2.
Methods
The study screened patients who were involved in all types of sports for anterior cruciate ligament (ACL) reconstruction (hamstring and patellar tendon autografts). All participants were included during the RTS phase (90-180 days after ACL reconstruction). Reinjury anxiety, fear of reinjury, kinesiophobia, perceived stress, anxiety, depression, knee confidence, self-esteem, optimism, coping, and pain were measured. Hierarchical cluster analysis (Ward method) and analysis of variance were performed. In the second year after surgery, patients were recontacted by telephone to follow-up. RTS and reinjury were compared by profile type.
Results
A total of 162 athletes were initially included, of whom 123 responded regarding RTS and reinjury. Cluster analysis showed a 4-cluster solution (χ ² [21] = 428.59; λ = .064; P < .001). Profile 1 (27.8%) was characterized by moderate reinjury anxiety and no depression. Profile 2 (22.8%) was characterized by moderate reinjury anxiety and minor anxious-depressive reaction. Profile 3 (30.9%) was characterized by no reinjury anxiety, no depression, and high confidence. Profile 4 (18.5%) was characterized by high anxiety, high depression, and low confidence. Profile 4 had the lowest self-esteem and optimism scores compared with profile 3 ( P < .001). In addition, a higher percentage of men was found in profile 3 as opposed to profile 4 (χ ² [3] = 11.35; P < .01). Profile 4 had the highest rate of non-RTS with 54.2% (profile 1: 14.3%, P = .001; profile 2: 25.0%, P = .031; profile 3: 22.2%, P = .011). Finally, patients with profile 3 had a higher risk of reinjury (13.9%) than those with profile 4 (0%) ( P = .047), who had an extremely conservative RTS.
Conclusion
The different profiles will affect RTS, but also the risk of reinjury exclusively for profiles 3 and 4. Rehabilitation management will probably require all stakeholders to understand psychological profiles of athletes to develop an on-demand rehabilitation plan.
Cognitive behavioural therapy (CBT) for tinnitus is a collective term for many psychotherapeutic techniques used in combination to address tinnitus-related distress and interference in daily life. In other words, CBT is not one “pure”, discrete, standardised treatment, nor is the goal of CBT to remove or cure a person of their tinnitus. Immediately, this hints at the strengths and challenges associated with this multi-faceted psychological treatment. This chapter provides you, the reader, with an overview of why a psychological treatment such as CBT might be relevant and applicable to tinnitus distress, what it is, the evidence base underpinning it, and future directions in which CBT might develop.
A primary goal of rehabilitation is to produce optimal health-related quality of life outcomes, which includes returning patients to their desired level of activity. Injury-related fear, kinesiophobia, and fear-avoidance beliefs are psychological factors that negatively impact health-related quality of life and are associated with decreased levels of physical activity. Conversely, increased levels of self-efficacy have been linked to favorable rehabilitation outcomes. To promote full recovery and optimal health-related quality of life, the rehabilitation process should consider addressing self-efficacy and injury-related fear (e.g., kinesiophobia, fear-avoidance beliefs). Therefore, the purpose of this paper is to introduce a theoretical framework which integrates self-efficacy theory and the Fear-Avoidance Model to mitigate injury-related fear and optimize patient outcomes following musculoskeletal injury. The intention of this theoretical framework is to provide clinicians with psychosocial interventions to improve self-efficacy and prevent the progression of injury-related fear at varying times throughout the rehabilitation process.
Background and Objectives
The learning healthcare system (LHS) has been developed to integrate patients' clinical data into clinical decisions and improve treatment outcomes. Having little guidance on this integration process, we aim to explain (a) an applicable analytic tool for clinicians to evaluate the clinical outcomes at a group and an individual level and (b) our quality improvement (QI) project, analyzing the outcomes of a new outpatient pain rehabilitation program (“Back‐in‐Action”: BIA) and applying the analysis results to modify our clinical practice.
Methods
Through our LHS (CHOIR; https://choir.stanford.edu ), we administered the Pain Catastrophizing Scale (PCS), Chronic Pain Acceptance Questionnaire (CPAQ), and Patient‐Reported Outcomes Measures (PROMIS)® before and after BIA. After searching for appropriate analytic tools, we decided to use the Reliable Change Index (RCI) to determine if an observed change in the direction of better (improvement) or worse (deterioration) would be beyond or within the measurement error (no change).
Results
Our RCI calculations revealed that at least a 9‐point decrease in the PCS scores and 10‐point increase in the CPAQ scores would indicate reliable improvement. RCIs for the PROMIS measures ranged from 5 to 8 T ‐score points (i.e., 0.5–0.8 SD). When evaluating change scores of the PCS, CPAQ, and PROMIS measures, we found that 94% of patients showed improvement in at least one domain after BIA and 6% showed no reliable improvement.
Conclusions
Our QI project revealed RCI as a useful tool to evaluate treatment outcomes at a group and an individual level, and RCI could be incorporated into the LHS to generate a progress report automatically for clinicians. We further explained how clinicians could use RCI results to modify a clinical practice, to improve the outcomes of a pain program, and to develop individualized care plans. Lastly, we suggested future research areas to improve the LHS application in pain practice.
Background
Pain is a major socio-psychological problem worldwide. Chronic pain has a negative effect on areas of psychological functioning such as depression, anxiety, and perceived stress.
Aim
The present study investigated the mediating role of experiential avoidance in the relationship between chronic pain and pain anxiety with pain disability.
Methods
Participants were treatment-seeking patients (N = 361) at an outpatient pain clinic in Shiraz (Fars, Iran). The Multidimensional Pain Inventory (MPI), Pain Anxiety Symptom Scale (PASS-20), Pain Disability Questionnaire (PDQ), and Acceptance and Action Questionnaire-II (AAQ-II) were used to measure multidimensional pain, anxiety, pain disability, experiential avoidance, and pain severity.
Results
The results of the correlation revealed that a significant relationship exists between multidimensional pain and pain anxiety, pain disability, and experiential avoidance. Experiential avoidance mediated the associations from multidimensional pain and pain disability significantly. Also, experiential avoidance moderated associations between pain anxiety and pain disability significantly. In general, Structural Equation Modeling (SEM) showed that experiential avoidance mediated the relationship between multidimensional pain and pain anxiety with pain disability.
Conclusion
In general, the results revealed that experiential avoidance can mediate the relationship among pain, pain anxiety, and pain disability as a maladaptive regulation strategy. The results obtained from this study seem to introduce experiential avoidance as a vulnerability factor effectively.
Presents an integrative theoretical framework to explain and to predict psychological changes achieved by different modes of treatment. This theory states that psychological procedures, whatever their form, alter the level and strength of self-efficacy. It is hypothesized that expectations of personal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and aversive experiences. Persistence in activities that are subjectively threatening but in fact relatively safe produces, through experiences of mastery, further enhancement of self-efficacy and corresponding reductions in defensive behavior. In the proposed model, expectations of personal efficacy are derived from 4 principal sources of information: performance accomplishments, vicarious experience, verbal persuasion, and physiological states. Factors influencing the cognitive processing of efficacy information arise from enactive, vicarious, exhortative, and emotive sources. The differential power of diverse therapeutic procedures is analyzed in terms of the postulated cognitive mechanism of operation. Findings are reported from microanalyses of enactive, vicarious, and emotive modes of treatment that support the hypothesized relationship between perceived self-efficacy and behavioral changes. (21/2 p ref)
It is now well established that in chronic low back pain, there is no direct relationship between impairments, pain, and disability. From a cognitive-behavioral perspective, pain disability is not only influenced by the organic pathology, but also by cognitive-perceptual, psychophysiological, and motoric-environmental factors. This paper focuses on the role of specific beliefs that are associated with avoidance of activities. These beliefs are related to fear of movement and physical activity, which is (wrongfully) assumed to cause (re)injury. Two studies are presented, of which the first examines the factor structure of the Tampa Scale for Kinesiophobia (TSK), a recently developed questionnaire that is aimed at quantifying fear of movement/(re)injury. In the second study, the value of fear of movement/(re)injury in predicting disability levels is analyzed, when the biomedical status of the patient and current pain intensity levels are controlled for. In addition, the determinants of fear of movement/(re)injury are examined. The discussion focuses on the clinical relevance of the fear-avoidance model in relation to risk assessment, assessment of functional capacity, and secondary prevention.
In Study 1, the Pain Catastrophizing Scale (PCS) was administered to 425 undergraduates. Analyses yielded a three component solution comprising (a) rumination, (b) magnification, and (c) helplessness. In Study 2, 30 undergraduate participants were classified as catastrophizers (n = 15) or noncatastrophizers (n = 15) on the basis of their PCS scores and participated in an cold pressor procedure. Catastrophizers reported significantly more negative pain-related thoughts, greater emotional distress, and greater pain intensity than noncatastrophizers. Study 3 examined the relation between PCS scores, negative pain-related thoughts, and distress in 28 individuals undergoing an aversive electrodiagnostic medical procedure. Catastrophizers reported more negative pain-related thoughts, more emotional distress, and more pain than noncatastrophizers. Study 4 examined the relation between the PCS and measures of depression, trait anxiety, negative affectivity, and fear of pain. Analyses revealed moderate correlations among these measures, but only the PCS contributed significant unique variance to the prediction of pain intensity.
In Study I, the Pain Catastrophizing Scale (PCS) was administered to 425 undergraduates. Analyses yielded a three component solution comprising (a) rumination, (b) magnification, and (c) helplessness. In Study 2, 30 undergraduate participants were classified as catastrophizers (
n = 15) or noncatastrophizers (
n = 15) on the basis of their PCS scores and participated in a cold pressor procedure. Catastrophizers reported significantly more negative pain-related thoughts, greater emotional distress, and greater pain intensity than noncatastrophizers. Study 3 examined the relation between PCS scores, negative pain-related thoughts, and distress in 28 individuals undergoing an aversive electrodiagnostic medical procedure. Catastrophizers reported more negative pain-related thoughts, more emotional distress, and more pain than noncatastrophizers. Study 4 examined the relation between the PCS and measures of depression, trait anxiety, negative affectivity, and fear of pain. Analyses revealed moderate correlations among these measures, but only the PCS contributed significant unique variance to the prediction of pain intensity. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The complexity of chronic pain has represented a major dilemma for clinical researchers interested in the reliable and valid assessment of the problem and the evaluation of treatment approaches. The West Haven-Yale Multidimensional Pain Inventory (WHYMPI) was developed in order to fill a widely recognized void in the assessment of clinical pain. Assets of the inventory are its brevity and clarity, its foundation in contemporary psychological theory, its multidimensional focus, and its strong psychometric properties. Three parts of the inventory, comprised of 12 scales, examine the impact of pain on the patients' lives, the responses of others to the patients' communications of pain, and the extent to which patients participate in common daily activities. The instrument is recommended for use in conjunction with behavioral and psychophysiological assessment strategies in the evaluation of chronic pain patients in clinical settings. The utility of the WHYMPI in empirical investigations of chronic pain is also discussed.
Abstract Fear-avoidance beliefs and catastrophizing have been implicated in chronic pain and theoretical models have been developed that feature these factor in the transition from acute to chronic pain. However, little has been done to determine whether these factors occur in the general population or whether they arc associated with the inception of an episode of neck or back pain. The aim of this study was to evaluate prospectively the effects of fear-avoidance beliefs and catastrophizing on the development of an episode of self-reported pain and associated physical functioning. To achieve this, we selected a sample of 415 people from the general population who reported no spinal pain during the past year. At the pretest a battery of questionnaires was administered to assess beliefs about pain and activity and it featured the Pain Catastrophizing Scale and a modified version of the Fear-Avoidance Beliefs Questionnaire. One year later outcome was evaluated by self-reports of the occurrence of a pain episode as well as a self-administered physical function test. The results showed that scores on both fear-avoidme and cabstrophizing were quite low. During the one year follow-up, 19% of the sample suffered an episode of back pain. Those with scores above the median on fear-avoidance beliefs at the pretest had twice the risk of suffering an episode of back pain and a 1.7 times higher risk of lowered physical function at the follow-up. Catastrophizing was somewhat less salient, increasing the risk of pain or lowered function by 1.5. but with confidence intervals falling below unity. These data indicate that fear-avoidance beliefs may be involved at a very early pint in the development of pain and associated activity problems in people with back pain. Theoretically. our results support the idea that fear-avoidance beliefs may develop in an interaction with the experience of pain. Clinically, the results suggest that catastrophizing and particularly fear-avoidance beliefs are important in the development of a pain problem and might be of use in screening procedures.
Theoretical as well as methodological issues associated with psychophysiological mechanisms of chronic pain syndromes are reviewed and discussed. Results of studies on psychophysiological responses in patients with recurrent headaches, chronic back pain, and temporomandibular pain disorders are presented. These studies are evaluated on the basis of a set of 12 theoretical and methodological criteria that include diagnostic procedures, use of control groups, sample description, use of multiple and relevant physiological measures, introduction of ecologically valid and actually stress-inducing stressors, use of adequate adaptation and baseline periods, adequacy of data acquisition, and analysis. Results on baseline levels, reactivity to stress and pain stimuli, and return to baseline levels are presented. When only the most methodologically sound studies are included, the data suggest that baseline levels, regardless of type of physiological measure, are not generally elevated in chronic pain patients. The presence of symptom-specific stress-related psychophysiological responses is more commonly observed, and the evidence on return to baseline is at this time inconclusive.
Most current models in health psychology assume that stress adversely affects physical health. We re-examined this assumption by reviewing extensive data from the literature and from six samples of our own, in which we collected measures of personality, health and fitness, stress, and current emotional functioning. Results indicate that self-report health measures reflect a pervasive mood disposition of negative affectivity (NA); self-report stress scales also contain a substantial NA component. However, although NA is correlated with health compliant scales, it is not strongly or consistently related to actual, long-term health status, and thus will act as a general nuisance factor in health research. Because self-report measures of stress and health both contain a significant NA component, correlations between such measures likely overestimate the true association between stress and health. Results demonstrate the importance of including different types of health measures in health psychology research.
This study compares the responsiveness of three instruments of functional status: two disease-specific questionnaires (Oswestry and Roland Disability Questionnaires), and a patient-specific method (severity of the main complaint). We compared changes over time of functional status instruments with pain rated on a visual analog scale. Two strategies for evaluating the responsiveness in terms of sensitivity to change and specificity to change were used: effect size statistics and receiver-operating characteristic method. We chose global perceived effect as external criterion. A cohort of 81 patients with non-specific low back pain for at least 6 weeks assessed these measures before and after 5 weeks of treatment. According to the external criterion 38 patients improved. The results of both strategies were the same. All instruments were able to discriminate between improvement and non-improvement. The effect size statistics of the instruments were higher in the improved group than in the non-improved group. For each instrument the receiver-operating characteristic curves showed some discriminative ability. The curves for the Roland Questionnaire and pain were closer to the upper left than the curves for the other instruments. The sensitivity to change of the rating of Oswestry Questionnaire was lower than that of the other instruments. The main complaint was not very specific to change. The two strategies for evaluating the responsiveness were very useful and appeared to complement each other.
Despite increasing advances in medical technology, the cost of musculoskeletal incapacity, particularly low-back pain, in terms of sickness benefits, invalidity benefits and associated allowances has led to a fundamental reconsideration of the nature of chronic incapacity. Recent reports from the United Kingdom and the United States of America, in their recommendations for a comprehensive multidisciplinary assessment for patients still symptomatic at six weeks, are based on the clear assumption that a significant proportion of chronic incapacity is preventable. Such a proposition represents a fundamental challenge to much of current medical practice.
This study compares the responsiveness of three instruments of functional status: two disease-specific questionnaires (Oswestry and Roland Disability Questionnaires), and a patient-specific method (severity of the main complaint). We compared changes over time of functional status instruments with pain rated on a visual analog scale. Two strategies for evaluating the responsiveness in terms of sensitivity to change and specificity to change were used: effect size statistics and receiver-operating characteristic method. We chose global perceived effect as external criterion.A cohort of 81 patients with non-specific low back pain for at least 6 weeks assessed these measures before and after 5 weeks of treatment. According to the external criterion 38 patients improved. The results of both strategies were the same. All instruments were able to discriminate between improvement and non-improvement. The effect size statistics of the instruments were higher in the improved group than in the non-improved group. For each instrument the receiver-operating characteristic curves showed some discriminative ability. The curves for the Roland Questionnaire and pain were closer to the upper left than the curves for the other instruments. The sensitivity to change of the rating of Oswestry Questionnaire was lower than that of the other instruments. The main complaint was not very specific to change. The two strategies for evaluating the responsiveness were very useful and appeared to complement each other.
Patterns of walking and concomitant pain behavior were compared in a group of chronic low back patients (n = 18) and normal controls (n = 18). Subjects were asked to walk a 5 m course. A transducer placed in the subjects' shoes produced a force proportional signal that permitted measurement of walking parameters. Subjects were videotaped in order to record the occurrence of 5 specific pain behaviors: guarding, bracing, rubbing the painful area, grimacing and sighing. Data analysis revealed significant differences in walking patterns of the patients and controls. Patients walked more slowly, took shorter steps and did not show the symmetrical gait patterns evident in normal controls. Patients also exhibited much higher levels of pain behavior. The gait of patients receiving disability payments or taking narcotics differed significantly from those who were not. Patients receiving disability payments had significantly longer stride lengths and swing time than patients not receiving disability/financial compensation payments. Patients taking narcotics showed longer single limb support time for the left leg than those who were not. By combining objective measures of gait and motor pain behaviors, clinicians and researchers may be able to more objectively evaluate factors that may affect patient behavior and measure the effects of interventions designed to modify behavior.
Pain is better classified as an awareness of a need-state than as a sensation. It serves more to promote healing than to avoid injury. It has more in common with the phenomena of hunger and thirst than it has with seeing or hearing. The period after injury is divided into the immediate, acute and chronic stages. In each stage it is shown that pain has only a weak connection to injury but a strong connection to the body state.
The purpose of the present article is to provide unification to a number of somewhat disparate themes in the chronic pain and phobia literature. First, we present a summary review of the early writings and current theoretical perspectives regarding the role of avoidance in the maintenance of chronic pain. Second, we present an integrative review of recent empirical investigations of fear and avoidance in patients with chronic musculoskeletal pain, relating the findings to existing cognitive-behavioral theoretical positions. We also discuss several new and emerging lines of investigation, specifically related to information processing and anxiety sensitivity, which appear to be closely linked to pain-related avoidance behavior. Finally, we discuss the implications of the recent empirical findings for the assessment and treatment of individuals who experience disabling chronic musculoskeletal pain and suggest possible avenues for future investigation.
This immensely practical volume describes the rationale, development, and utilization of cognitive-behavioral techniques in promoting health, preventing disease, and treating illness, with a particular focus on pain management. An ideal resource for a wide range of practitioners and researchers, the book's coverage of pain management includes theoretical, research, and clinical issues, and includes illustrative case material.
illustrative biopsychosocial model of pain
diathesis-stress model outlined noted the contribution of patients' appraisals and socioenvironmental parameters in the development and maintenance of symptoms
summarize the current status of pain treatment (PsycINFO Database Record (c) 2012 APA, all rights reserved)
A cross-sectional investigation of psychosocial variables in 63 female employees matched for experienced pain was conducted
to study the difference between back pain sufferers who were working (Copers) and those who were off work (Dysfunctional).
The subjects reported moderate to severe pain often or always during the past year and were employed at the same hospital.
Thirty-seven women who had not been off work for pain made up the Copers group, whereas 26 women who had been off work for
their pain made up the Dysfunctional group, subjects were interviewed and completed a battery of questionnaires designed to
penetrate level of dysfunction, perceived health, work and social satisfaction, perceived workload, coping strategies, and
pain beliefs. Multiple covariate analyses that controlled for perceived workload, smoking, low-back mobility, and obesity
revealed significant differences between the groups on levels of functioning, pain beliefs, and coping strategies used. Dysfunctional
subjects had stronger beliefs that pain was directly related to activities, that they had little control over their pain,
that their health was poor, and that they tended to focus more on their pain. A discriminant analysis correctly classified
83% of the subjects as to work status based on six psychosocial variables. These results not only demonstrate the importance
of psychosocial factors in back pain, but underscore the fact that work absence for back pain may be controlled by psychological
factors related to beliefs and coping strategies. Future research may attempt to use these factors in the screening of patients.
The three-systems model of chronic pain emphasizes the partially independent relationship among physiological, gross motor and verbal-cognitive responses of chronic pain patients. This study describes the development of an assessment instrument representing a measure for the verbal-cognitive response system of chronic pain. Fifty items, each of which is assigned to one of five factors (pain impact, catastrophizing, outcome efficacy, acquiescence and reliance on health care) constitute the new Pain Cognition List (PCL). The PCL was developed using a Dutch back pain population and proves to be stable across sex and back pain diagnosis. By means of three experiments the PCL is shown to be reliable and sufficiently valid. The PCL might be a promising tool for identifying pain patients whose pain problem is mainly controlled by cognitive factors.
Chronic low back pain (CLBP) is a major clinical problem with a substantial socio-economical impact. Today, diagnosis and therapy are insufficient, and knowledge concerning interaction between musculoskeletal pain and motor performance is lacking. Most studies in this field have been performed under static conditions which may not represent CLBP patients' daily-life routines. A standardized way to study the sensory-motor interaction under controlled motor performance is to induce experimental muscle pain by i.m. injection of hypertonic saline. The aim of the present controlled study was to analyze and compare electromyographic (EMG) activity of and coordination between lumbar muscles (8 paraspinal recordings) during gait in 10 patients with CLBP and in 10 volunteers exposed to experimental back muscle pain induced by bolus injection of 5% hypertonic saline. When the results are compared to sex- and age-matched controls, the CLBP patients showed significantly increased EMG activity in the swing phase; a phase where the lumbar muscles are normally silent. These changes correlated significantly to the intensity of the back pain. Similar EMG patterns were found in the experimental study together with a reduced peak EMG activity in the period during double stance where the back muscles are normally active. Generally, these changes were localized ipsilaterally to the site of pain induction. The clinical and experimental findings indicate that musculoskeletal pain modulates motor performance during gait probably via reflex pathways. Initially, these EMG changes may be interpreted as a functional adaptation to muscle pain, but the consequences of chronic altered muscle performance are not known. New possibilities to monitor and investigate altered motor performance may help to develop more rational therapies for CLBP patients.
The purposes of this article are to summarize the author's expectancy model of fear, review the recent studies evaluating this model, and suggest directions for future research. Reiss' expectancy model holds that there are three fundamental fears (called sensitivities): the fear of injury, the fear of anxiety, and the fear of negative evaluation. Thus far, research on this model has focused on the fear of anxiety (anxiety sensitivity). The major research findings are as follows: simple phobias sometimes are motivated by expectations of panic attacks; the Anxiety Sensitivity Index (ASI) is a valid and unique measure of individual differences in the fear of anxiety sensations; the ASI is superior to measures of trait anxiety in the assessment of panic disorder; anxiety sensitivity is associated with agoraphobia, simple phobia, panic disorder, and substance abuse; and anxiety sensitivity is strongly associated with fearfulness. There is some preliminary support for the hypothesis that anxiety sensitivity is a risk factor for panic disorder. It is suggested that future researchers evaluate the hypotheses that anxiety and fear are distinct phenomena; that panic attacks are intense states of fear (not intense states of anxiety); and that anxiety sensitivity is a risk factor for both fearfulness and panic disorder.
Cognitive and behavioral pain coping strategies were assessed by means of questionnaire in a sample of 61 chronic low back pain patients. Data analysis indicated that the questionnaire was internally reliable. While patients reported using a variety of coping strategies, certain strategies were used frequently whereas others were rarely used. Three factors: (a) Cognitive Coping and Suppression, (b) Helplessness and (c) Diverting Attention or Praying, accounted for a large proportion of variance in questionnaire responses. These 3 factors were found to be predictive of measures of behavioral and emotional adjustment to chronic pain above and beyond what may be predicted on the basis of patient history variables (length of continuous pain, disability status and number of pain surgeries) and the tendency of patients to somaticize. Each of the 3 coping factors was related to specific measures of adjustment to chronic pain.
This paper describes the development and preliminary validation of a questionnaire designed to assess five attitudes considered important in the long-term adjustment of chronic pain patients. The specific subscales of the questionnaire were chosen to represent attitudes believed to influence the ways by which chronic pain patients manage their pain. Following the development of five reliable subscales, correlations of the subscales with self-reported pain behaviors and coping strategies were calculated, providing preliminary support for the concurrent validity of the instrument.
Preoccupation with or attention to pain may influence perceived pain severity and other pain responses. The purpose of this study was to investigate attention to pain in persons with chronic pain. Participants for this study were patients (N = 80, 58.8% female) with chronic low back pain referred to a university pain clinic. A measure of attention to pain, the Pain Vigilance and Awareness Questionnaire (PVAQ), was constructed for this study. It was intended to assess a number of related responses including awareness, vigilance, preoccupation, and observation of pain. The PVAQ showed adequate internal consistency and temporal stability over a short interval. PVAQ scores were positively correlated with private body consciousness and cognitive disability, and negatively correlated with a measure of ignoring pain, supporting their validity. The results of this study show that persons with chronic low back pain who report greater attention to pain also report higher pain intensity, emotional distress, psychosocial disability, and pain-related health care utilization. Regression analyses showed that level of attention to pain remained a significant predictor of distress, disability, and health care utilization independent of pain intensity and relevant demographic variables. These results provide preliminary support for a behavioral conceptualization of attention to pain.
• Fear, rage and pain, and the pangs of hunger are all primitive experiences which human beings share with the lower animals. These experiences are properly classed as among the most powerful that determine the action of men and beasts. A knowledge of the conditions which attend these experiences, therefore, is of general and fundamental importance in the interpretation of behavior. During the past four years there has been conducted, in the Harvard Physiological Laboratory, a series of investigations concerned with the bodily changes which occur in conjunction with pain, hunger and the major emotions. A group of remarkable alterations in the bodily economy have been discovered. Because these physiological adaptations are interesting both in themselves and in their interpretation, it has seemed worth while to gather together in convenient form the original accounts of the experiments, which have been published in various American medical and physiological journals. I have, however, attempted to arrange the results and discussions in an orderly and consecutive manner, and I have tried also to eliminate or incidentally to explain the technical terms, so that the exposition will be easily understood by any intelligent reader even though not trained in the medical sciences. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
• Fear, rage and pain, and the pangs of hunger are all primitive experiences which human beings share with the lower animals. These experiences are properly classed as among the most powerful that determine the action of men and beasts. A knowledge of the conditions which attend these experiences, therefore, is of general and fundamental importance in the interpretation of behavior. During the past four years there has been conducted, in the Harvard Physiological Laboratory, a series of investigations concerned with the bodily changes which occur in conjunction with pain, hunger and the major emotions. A group of remarkable alterations in the bodily economy have been discovered. Because these physiological adaptations are interesting both in themselves and in their interpretation, it has seemed worth while to gather together in convenient form the original accounts of the experiments, which have been published in various American medical and physiological journals. I have, however, attempted to arrange the results and discussions in an orderly and consecutive manner, and I have tried also to eliminate or incidentally to explain the technical terms, so that the exposition will be easily understood by any intelligent reader even though not trained in the medical sciences. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
The literature indicates a substantial overlap between chronic pain and posttraumatic stress disorder (PTSD) symptoms in individuals who sustain accidental injury. To date, however, there have been no studies of PTSD symptoms in individuals who experience work-related injury. Consequently, we assessed 139 consecutive injured workers using the Modified PTSD Symptom Scale (Falsetti, Resnick, & Kirkpatrick, 1993), as well as a number of general measures of psychopathology. Most participants reported chronic pain and all were receiving workers compensation. Results indicated that 34.7% and 18.2% of the sample reported symptoms consistent with PTSD and partial PTSD, respectively. When PTSD symptom frequency and severity were considered criterion variables in multiple regression analyses, depression was found to be significantly associated with the former and anxiety sensitivity, social fears, and somatic focus with the later. Finally, these measures of general psychopathology correctly classified 78.6% of individuals with PTSD and 81.3% of those with no PTSD. These results suggest that a considerable proportion of injured workers display symptoms consistent with PTSD and that these symptoms are related to general negative affect. Implications, including the suggestion of clinical intake screening of PTSD in this population, are discussed.
In the treatment of patients with pain, measures related to (pain) behaviour are of major importance. Ambulatory activity monitoring can be used to obtain insight into actual behaviour. This study was designed to validate the Activity Monitor (AM), an instrument based on long-term ambulatory monitoring of accelerometer signals, to assess several physical activities during normal daily life. Ten failed back surgery (FBS) patients performed a number of functional activities in and around their own houses. During the measurements, continuous ambulatory registrations of accelerometer signals were made, based on four body-mounted accelerometers (one on each upper leg, two on the trunk). Video recordings made simultaneously with the measurements were used as a reference. The continuous output of the AM (postures, transitions, dynamic activities) was compared with visual analysis of the videotapes. The overall results showed an agreement between AM output and video analysis of 87% (inter subject range: 83-88%). The maximal error in the determination of the duration of activities was 0.3%. The overall number of dynamic periods was determined well (AM: 359; video: 368), while the number of transitions was slightly overestimated (AM: 228; video: 205). The results when using the three-sensor version of the AM were somewhat less accurate (overall agreement from 87% to 82%). The AM appeared to be a valid instrument to quantify aspects of behaviour of FPS patients, such as duration of activities and number of transitions. This new technique of ambulatory measurement of mobility activities seems to be a relevant and promising extension of the techniques currently used in the evaluation of pain treatment.
The present article presents an integrative theoretical framework to explain and to predict psychological changes achieved by different modes of treatment. This theory states that psychological procedures, whatever their form, alter the level and strength of self-efficacy. It is hypothesized that expectations of per- sonal efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of ob- stacles and aversive experiences. Persistence in activities that are subjectively threatening but in fact relatively safe produces, through experiences of mastery, further enhancement of self-efficacy and corresponding reductions in defensive behavior. In the proposed model, expectations of personal efficacy are derived from four principal sources of information: performance accomplishments, vicarious experience, verbal persuasion, and physiological states. The more de- pendable the experiential sources, the greater are the changes in perceived self- efficacy. A number of factors are identified as influencing the cognitive processing of efficacy information arising from enactive, vicarious, exhortative, and emotive sources. The differential power of diverse therapeutic procedures is analyzed in terms of the postulated cognitive mechanism of operation. Findings are reported from microanalyses of enactive, vicarious, and emotive modes of treatment that support the hypothesized relationship between perceived self-efficacy and be- havioral changes. Possible directions for further research are discussed.
Symptom-specific psychophysiological responding was assessed in 20 chronic back pain patients, 20 patients suffering from temporomandibular pain and dysfunction, and 20 matched healthy controls. Surface EMG from the lower and upper back, the masseter, and the biceps muscles, and heart rate and skin conductance level were continuously recorded during adaptation, resting baseline, and stressful and neutral imagery phases. Univariate and multivariate analyses of variance were performed on raw data as well as data corrected for autocorrelation. The results showed significantly higher EMG reactivity which was lateralized to the left side at the patients' site of pain but not distal sites. This hyperreactivity was observed only during stressful imagery. The healthy controls displayed a significantly higher response in heart rate, but skin conductance level was not significantly different. The results are interpreted as indicative of idiosyncratic muscular response patterns to personally relevant situations at the site of pain in patients suffering from chronic muscular pain.
Fear of pain has been implicated in the development and maintenance of chronic pain behavior. Consistent with conceptualizations of anxiety as occurring within three response modes, this paper introduces an instrument to measure fear of pain across cognitive, overt behavioral, and physiological domains. The Pain Anxiety Symptoms Scale (PASS) was administered to 104 consecutive referrals to a multidisciplinary pain clinic. The alpha coefficients were 0.94 for the total scale and ranged from 0.81 to 0.89 for the subscales. Validity was supported by significant correlations with measures of anxiety and disability. Regression analyses controlling for measures of emotional distress and pain showed that the PASS made a significant and unique contribution to the prediction of disability and interference due to pain. Evidence presented here supports the potential utility of the PASS in the continued study of fear of pain and its contribution to the development and maintenance of pain behaviors. Factor analysis and behavioral validation studies are in progress.
The aim of this study was to determine whether graded activity restored occupational function in industrial blue-collar workers who were sick-listed for 8 weeks because of subacute, nonspecific, mechanical low back pain (LBP). Patients with LBP, who had been examined by an orthopedic surgeon and a social worker, were randomly assigned to either an activity group (n = 51) or a control group (n = 52). Patients with defined orthopedic, medical, or psychiatric diagnoses were excluded before randomization. The graded activity program consisted of four parts: (1) measurements of functional capacity; (2) a work-place visit; (3) back school education; and (4) an individual, submaximal, gradually increased exercise program, with an operant-conditioning behavioral approach, based on the results of the tests and the demands of the patient's work. Records of the amount of sick leave taken over a 3-year period (ie, the 1-year periods before, during, and after intervention) were obtained from each patient's Social Insurance Office. The patients in the activity group returned to work significantly earlier than did the patients in the control group. The median number of physical therapist appointments before return to work was 5, and the average number of appointments was 10.7 (SD = 12.3). The average duration of sick leave attributable to LBP during the second follow-up year was 12.1 weeks (SD = 18.4) in the activity group and 19.6 weeks (SD = 20.7) in the control group. Four patients in the control group and 1 patient in the activity group received permanent disability pensions. The graded activity program made the patients occupationally functional again, as measured by return to work and significantly reduced long-term sick leave.
To determine differences in the mix of patients among medical specialties and among organizational systems of care.
Cross-sectional analysis of 20,158 adults (greater than or equal to 18 years of age) who visited providers' offices during 9-day screening periods in 1986. Patient and physician information was obtained by self-administered, standardized questionnaires.
Offices of 349 physicians practicing family medicine, internal medicine, endocrinology, and cardiology within health maintenance organizations, large multispecialty groups, and solo or small single-specialty group practices in three major US cities.
Demographic characteristics, prevalence of chronic disease, disease-specific severity of illness, and functional status and well-being.
Among patients with selected physician-reported chronic illnesses (diabetes, hypertension, recent myocardial infarction, or congestive heart failure), increasing levels of severity were associated with decreasing levels of functional status and well-being and with increased hospitalizations, more physician visits, and higher numbers of prescription drugs. Compared with patients of general internists, patients of cardiologists were older (56 vs 47 years, P less than .01), had worse functional status and well-being scores (P less than .01), and carried more chronic diagnoses (mean 1.32 vs 1.02, P less than .01); patients of family practitioners were younger (40 vs 47 years, P less than .01) and more functional (P less than .01), carried fewer chronic diagnoses (0.70 vs 1.02, P less than .01), and (among diabetic patients only) had lower disease-specific severity scores (2.06 vs 2.30 on a five-point scale, P less than .01). Compared with patients in health maintenance organizations, patients visiting solo practitioners under fee-for-service payment were older (50 vs 45 years, P less than .01) and sicker (had worse physical functioning) and had a higher mean number of chronic diagnoses (1.10 vs 0.93, P less than .01).
Patient mix is related to utilization and differs significantly across medical specialties and systems of care. These differences must be taken into account when interpreting variations in utilization and outcomes across specialties and systems, and when considering alternative policies for payment.
Cognitive theories of appraisal argue for the importance of beliefs as determinants of adjustment to stress. The current investigation sought to examine the relation between beliefs about chronic pain and adjustment in a group of chronic pain patients. Patients' belief in themselves as disabled was found to be inversely related to activity level for patients reporting low and medium levels of pain severity. This same belief correlated with professional services utilization and was negatively related to psychological functioning. Believing in a medical cure for pain was also positively related to professional services utilization. Finally, an expressed belief in the appropriateness of solicitous responses from family members was negatively related to psychological functioning for patients reporting relatively low levels of pain. Although these findings support the broad-based hypothesis that the illness-relevant beliefs of chronic pain patients are associated with their multidimensional pain adjustment, they emphasize the importance of beliefs concerning whether or not one is disabled by pain. The findings also highlight the fact that the belief/functioning relation is not always direct and can be moderated by perceived pain severity.
The effects of fear/anticipatory anxiety on the acoustic startle reflex were investigated in humans using a paradigm involving anticipation of electric shocks. The eyeblink component of the startle reflex, elicited by an abrupt auditory stimulus, was measured in 9 normal volunteers during either the anticipation of electric shocks (anticipatory anxiety) or periods in which no shocks were anticipated (safe period). The eyeblink was consistently higher in amplitude, and shorter in latency, during periods when the subjects anticipated shocks, compared to the safe periods. This effect could not be attributed solely to a reduction in habituation and was statistically significant before the subjects actually received any shock (a single 30 mA stimulation on the median nerve). These results indicate that anticipatory anxiety can be measured objectively in humans using the fear-potentiated startle reflex in a paradigm not actually requiring any shock. Because a great deal is known about the neuroanatomical and pharmacological mechanisms of fear-potentiated startle in laboratory animals, this test procedure may be especially useful in humans to investigate the neurobiological substrates of anxiety disorders and their pharmacological treatments.
Recent studies suggest that coping strategies play an important role in adjustment to chronic pain. Identification of factors that influence coping could potentially help clinicians facilitate the use of adaptive coping strategies by pain patients. According to social learning theory, self-efficacy beliefs (judgments regarding one's capabilities) and outcome expectancies (judgments regarding the consequences of behaviors) are significant determinants of coping behavior. This study tested hypotheses derived from social learning theory by examining the contributions of these beliefs to the prediction of coping behavior in chronic pain patients. One hundred and fourteen chronic pain patients completed measures of health-related dysfunction, pain severity, use of 8 coping strategies, and outcome and self-efficacy expectancies regarding these coping strategies. In support of social learning theory, and consistent with research in other areas, the patients' beliefs regarding their capabilities were strongly related to reported coping efforts. Beliefs about the consequences of coping efforts and their interaction with beliefs about capabilities were generally unrelated to coping. These results suggest that treatment should emphasize the actual practice and use of adaptive coping strategies over education about their outcome.
Hypochondriasis and other syndromes in which health anxiety is prominent are frequently seen in clinical practice and often pose problems of management. In contrast with other anxiety problems, the conceptualization and treatment of health anxiety has developed very little in recent years. Behavioural approaches to treatment have only recently been applied. In the present paper, current theoretical models are critically evaluated and a cognitive-behavioural approach is proposed to account for the development and maintenance of hypochondriacal problems. Principles of cognitive-behavioural treatment based on this approach are outlined, together with some suggestions for research.
In a study of 40 subjects, who twice underwent extensive dental treatment, the relationships between expectations and experiences of pain and of anxiety were investigated. Inaccurate expectations were adjusted in the same way as observed in the laboratory. Especially anxious subjects expected more pain and anxiety than they experienced, and they appeared to need more experiences before their predictions became accurate. In the course of time, the expectations (and memories) of anxious subjects returned to their original more inaccurate level of prediction. The results suggest that the old schema is ultimately reinstated if disconfirmations are few and far between. Anxious subjects did not experience more pain, but they did experience more anxiety than fearless subjects. Detailed investigation of processes of change after disconfirmation showed that anxiety experienced during treatment is a factor that plays a part in maintaining the problem of inaccurate expectations and fear of treatment. Theoretical and clinical implications of these findings are discussed.