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      Comparison of work-related fear-avoidance beliefs across different anatomical locations with musculoskeletal pain

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          The influence of work-related fear-avoidance on pain and function has been consistently reported for patients with musculoskeletal low back pain. Emerging evidence suggests similar influences exist for other anatomical locations of musculoskeletal pain, such as the cervical spine and extremities. However, research is limited in comparing work-related fear-avoidance and associations with clinical outcomes across different anatomical locations. The purpose of this study was to examine the associations between work-related fear-avoidance, gender, and clinical outcomes across four different musculoskeletal pain locations for patients being treated in an outpatient physical therapy setting.


          This study was a secondary analysis of data obtained prospectively from a cohort of 313 participants receiving physical therapy from an outpatient clinic.


          No interaction was found between gender and anatomical location of musculoskeletal pain on work-related fear-avoidance scores. Work-related fear-avoidance scores were higher in the cervical group versus the lower extremity group; however, there were no other differences across anatomical locations. Work-related fear-avoidance influenced intake pain intensity in patients with spine pain but not extremity pain. Conversely, work-related fear-avoidance influenced intake function for participants with extremity pain but not spine pain. Similar results were observed for change scores, with higher work-related fear-avoidance being associated with more, not less, change in pain and function for certain anatomical locations.


          These findings suggest that work-related fear-avoidance is similar for patients experiencing musculoskeletal pain. However, associations between work-related fear-avoidance and clinical outcomes may differ based on the anatomical location of that pain. Further, increased work-related fear-avoidance may not be indicative of poor clinical outcomes for this type of patient population.

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          Most cited references 30

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          Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance.

          Two studies are presented that investigated 'fear of movement/(re)injury' in chronic musculoskeletal pain and its relation to behavioral performance. The 1st study examines the relation among fear of movement/(re)injury (as measured with the Dutch version of the Tampa Scale for Kinesiophobia (TSK-DV)) (Kori et al. 1990), biographical variables (age, pain duration, gender, use of supportive equipment, compensation status), pain-related variables (pain intensity, pain cognitions, pain coping) and affective distress (fear and depression) in a group of 103 chronic low back pain (CLBP) patients. In the 2nd study, motoric, psychophysiologic and self-report measures of fear are taken from 33 CLBP patients who are exposed to a single and relatively simple movement. Generally, findings demonstrated that the fear of movement/(re)injury is related to gender and compensation status, and more closely to measures of catastrophizing and depression, but in a much lesser degree to pain coping and pain intensity. Furthermore, subjects who report a high degree of fear of movement/(re)injury show more fear and escape/avoidance when exposed to a simple movement. The discussion focuses on the clinical relevance of the construct of fear of movement/(re)injury and research questions that remain to be answered.
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            Analysis of outcome measures for persons with patellofemoral pain: which are reliable and valid?

            To examine the test-retest reliability, validity, and responsiveness of several outcome measures in the treatment of patellofemoral pain. Evaluation of the clinimetric properties of individual outcome measures for patellofemoral pain treatment, using data collected from a previously published randomized controlled trial (RCT). General community and private practice. The data from 71 persons enrolled in an RCT of a conservative intervention for patellofemoral pain were used to evaluate the measures' validity and responsiveness. A subset of this cohort (n=20) was used to assess reliability. Not applicable. Three 10-cm visual analog scales (VASs) for usual pain (VAS-U), worst pain (VAS-W), and pain on 6 aggravating activities (walking, running, squatting, sitting, ascending and descending stairs) (VAS-activity); the Functional Index Questionnaire (FIQ); the Anterior Knee Pain Scale (AKPS); and the global rating of change. The test-retest reliability ranged from poor (intraclass correlation coefficient [ICC]=.49) to good (ICC=.83), and the measures correlated moderately with each other (r range,.56-.72). Median change scores differed significantly between improved and unimproved persons for all measures. The effect sizes for VAS-U (.79), VAS-W (.88), and the AKPS (.98) were large, indicating greater responsiveness than the FIQ (.37) and VAS-activity (.66). Similarly, the AKPS and VAS-W were the most efficient measures for detecting a treatment effect when compared with a reference measure (VAS-U, which was assigned a value of 1). The minimal difference that patients or clinicians consider clinically important for the AKPS is 10 (out of 100) points and for the VAS it is 2cm (out of 10cm). The AKPS and VAS for usual or worst pain are reliable, valid, and responsive and are therefore recommended for future clinical trials or clinical practice in assessing treatment outcome in persons with patellofemoral pain.
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              The role of fear-avoidance beliefs in acute low back pain: relationships with current and future disability and work status.

              Fear-avoidance beliefs have been identified as an important psychosocial variable in patients with chronic disability doe to low back pain. The importance of fear-avoidance beliefs for individuals with acute low back pain has not been explored. Seventy-eight subjects with work-related low back pain of less than 3 weeks'duration were studied. Measurements of pain intensity, physical impairment, disability, nonorganic signs and symptoms, and depression were taken at the initial evaluation. Fear-avoidance beliefs were measured with the work and physical activity subscales of the Fear-avoidance Beliefs Questionnaire. Disability and work status were re-assessed after 4 weeks of physical therapy. Patterns of correlation between fear-avoidance beliefs and other concurrently-measured variables were similar to those reported in patients with chronic low back pain. Fear-avoidance beliefs did not explain a significant amount of the variability in initial disability levels after controlling for pain intensity and physical impairment. Fear-avoidance beliefs about work were significant predictors of 4-week disability and work status even after controlling for initial levels of pain intensity, physical impairment, and disability, and the type of therapy received. Fear-avoidance beliefs are present in patients with acute low back pain, and may be an important factor in explaining the transition from acute to chronic conditions. Screening for fear-avoidance beliefs may be useful for identifying patients at risk of prolonged disability and work absence.

                Author and article information

                J Pain Res
                Journal of Pain Research
                Dove Medical Press
                01 September 2011
                : 4
                : 253-262
                [1 ]Department of Physical Therapy, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
                [2 ]Life’s Work Physical Therapy, Portland, Oregon, USA
                [3 ]Department of Physical Therapy and Center for Pain Research and Behavioral Health, College of Public Health and Health Professions, University of Florida, Gainesville, Florida, USA
                Author notes
                Correspondence: Corey B Simon; Steven Z George, PO Box 100154, UFHSC, Gainesville, FL 32610-0154, USA, Tel +1 352 273 6085, Fax: +1 352 273 6109, Email coreysimon@ 123456phhp.ufl.edu ; szgeorge@ 123456phhp.ufl.edu
                © 2011 Simon et al, publisher and licensee Dove Medical Press Ltd.

                This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.

                Original Research

                Anesthesiology & Pain management

                fear, function, spine pain, pain intensity, musculoskeletal, gender, avoidance


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