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      How does pain lead to disability? A systematic review and meta-analysis of mediation studies in people with back and neck pain.

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          Abstract

          Disability is an important outcome from a clinical and public health perspective. However, it is unclear how disability develops in people with low back pain or neck pain. More specifically, the mechanisms by which pain leads to disability are not well understood. Mediation analysis is a way of investigating these mechanisms by examining the extent to which an intermediate variable explains the effect of an exposure on an outcome. This systematic review and meta-analysis aimed to identify and examine the extent to which putative mediators explain the effect of pain on disability in people with low back pain or neck pain. Five electronic databases were searched. We found 12 studies (N = 2961) that examined how pain leads to disability with mediation analysis. Standardized regression coefficients (β) of the indirect and total paths were pooled. We found evidence to show that self-efficacy (β = 0.23, 95% confidence interval [CI] = 0.10 to 0.34), psychological distress (β = 0.10, 95% CI = 0.01 to 0.18), and fear (β = 0.08, 95% CI = 0.01 to 0.14) mediated the relationship between pain and disability, but catastrophizing did not (β = 0.07, 95% CI = -0.06 to 0.19). The methodological quality of these studies was low, and we highlight potential areas for development. Nonetheless, the results suggest that there are significant mediating effects of self-efficacy, psychological distress, and fear, which underpins the direct targeting of these constructs in treatment.

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          Most cited references48

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          On the use of beta coefficients in meta-analysis.

          This research reports an investigation of the use of standardized regression (beta) coefficients in meta-analyses that use correlation coefficients as the effect-size metric. The investigation consisted of analyzing more than 1,700 corresponding beta coefficients and correlation coefficients harvested from published studies. Results indicate that, under certain conditions, using knowledge of corresponding beta coefficients to input missing correlations (effect sizes) generally produces relatively accurate and precise population effect-size estimates. Potential benefits from applying this knowledge include smaller sampling errors because of increased numbers of effect sizes and smaller non-sampling errors because of the inclusion of a broader array of research designs.
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            A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain.

            A systematic review of prospective cohort studies in low back pain. To evaluate the evidence implicating psychological factors in the development of chronicity in low back pain. The biopsychosocial model is gaining acceptance in low back pain, and has provided a basis for screening measurements, guidelines and interventions; however, to date, the unique contribution of psychological factors in the transition from an acute presentation to chronicity has not been rigorously assessed. A systematic literature search was followed by the application of three sets of criteria to each study: methodologic quality, quality of measurement of psychological factors, and quality of statistical analysis. Two reviewers blindly coded each study, followed by independent assessment by a statistician. Studies were divided into three environments: primary care settings, pain clinics, and workplace. Twenty-five publications (18 cohorts) included psychological factors at baseline. Six of these met acceptability criteria for methodology, psychological measurement, and statistical analysis. Increased risk of chronicity (persisting symptoms and/or disability) from psychological distress/depressive mood and, to a lesser extent, somatization emerged as the main findings. Acceptable evidence generally was not found for other psychological factors, although weak support emerged for the role of catastrophizing as a coping strategy. Psychological factors (notably distress, depressive mood, and somatization) are implicated in the transition to chronic low back pain. The development and testing of clinical interventions specifically targeting these factors is indicated. In view of the importance attributed to other psychological factors (particularly coping strategies and fear avoidance) there is a need to clarify their role in back-related disability through rigorous prospective studies.
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              Fear-avoidance model of chronic pain: the next generation.

              The fear-avoidance (FA) model of chronic pain describes how individuals experiencing acute pain may become trapped into a vicious circle of chronic disability and suffering. We propose to extend the FA model by adopting a motivational perspective on chronic pain and disability. A narrative review. There is ample evidence to support the validity of the FA model as originally formulated. There are, however, some key challenges that call for a next generation of the FA model. First, the FA model has its roots in psychopathology, and investigators will have to find a way to account for findings that do not easily fit within such framework. Second, the FA model needs to address the dynamics and complexities of disability and functional recovery. Third, the FA model should incorporate the idea that pain-related fear and avoidance occurs in a context of multiple and often competing personal goals. To address these 3 key challenges, we argue that the next generation of the FA model needs to more explicitly adopt a motivational perspective, one that is built around the organizing powers of goals and self-regulatory processes. Using this framework, the FA model is recast as capturing the persistent but futile attempts to solve pain-related problems to protect and restore life goals.
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                Author and article information

                Journal
                Pain
                Pain
                1872-6623
                0304-3959
                Jun 2015
                : 156
                : 6
                Affiliations
                [1 ] aNeuroscience Research Australia (NeuRA), Sydney, NSW, Australia bSchool of Medical Sciences, University of New South Wales, Sydney, NSW, Australia cSansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia dEMGO+ Institute, VU University Medical Centre, Amsterdam, the Netherlands eThe George Institute for Global Health, University of Sydney, Sydney, NSW, Australia fArthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Keele, Staffordshire, United Kingdom.
                Article
                10.1097/j.pain.0000000000000146
                25760473
                3c923a27-6fac-4f71-9435-83d230c99a44
                History

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