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Fear and avoidance in the development of a persistent musculoskeletal pain problem: implications for secondary prevention
Örebro University, Department of Behavioural, Social and Legal Sciences.ORCID iD: 0000-0001-9429-9012
2005 (English)Doctoral thesis, comprehensive summary (Other academic)Alternative title
Betydelsen av rädsla och undvikande i utvecklingen av ett långvarigt smärtproblem : implikationer för sekundär prevention (Swedish)
Abstract [en]

This dissertation focused on the role of fear and avoidance in the development of a persistent back pain problem. The first aim of this dissertation was to study when and how cognitive, affective and behavioral factors influence one another in the development of persistent pain and disability. The moderating role of pain duration on the relationship between psychological risk factors and dysfunction was studied, as well as the interrelationships between psychological risk factors within individuals.

The results suggest that pain duration may moderate the relationship between some of the psychological risk factors and function. In study two, depression and function were interrelated independent of stages of chronicity while the strength of the relationship between fear of movement and function increased across the stages. Further, the results suggest that there may be individual variability in the importance of psychological risk factors and in how these factors are interrelated within individuals. In study one and three profiles of psychological functioning emerged that were characterized by pain-related fear with and without depressed mood, by depressed mood only, and by low pain-related fear and no depressed mood. These profiles were meaningfully related to future disability.

The second aim of this dissertation was to test a new treatment that is designed to match patients with high levels of fear and avoidance. The results of study four show that this exposure treatment can produce significant decreases in fear and increases in function.

The results of the studies in this dissertation suggest that we need to assign a key role to psychological processes such as pain-related fear, depressed mood, and avoidance in our efforts to understand the development of persistent back pain disability. The results highlight that there may be several roads towards a persistent back pain problem and that the relationship between psychological factors and disability is not static but appears to change as a function of pain duration. This suggests that we need to know more about the process of development of persistent back pain disability and that future research should incorporate the role of time, as well as take into consideration that there may be individual variability in the importance of factors and their interactions. Lastly, the results suggest that secondary prevention of persistent back pain disability could be enhanced by addressing psychological processes at a much earlier time point than is currently practiced and by customizing interventions to the characteristics of the individual patient.

Place, publisher, year, edition, pages
Örebro: Örebro universitetsbibliotek , 2005. , p. 71
Series
Örebro Studies in Psychology, ISSN 1651-1328 ; 5
Keyword [en]
Psychology, pain-related fear, fear-avoidance model, back pain, disability, development, exposure
Keyword [sv]
Psykologi
National Category
Psychology
Research subject
Psychology
Identifiers
URN: urn:nbn:se:oru:diva-110ISBN: 91-7668-433-4 (print)OAI: oai:DiVA.org:oru-110DiVA, id: diva2:134643
Public defence
2005-05-20, Aulan, B-huset, Universitetssjukhuset, Örebro, 10:00 (English)
Opponent
Supervisors
Available from: 2005-04-29 Created: 2005-04-29 Last updated: 2017-10-18Bibliographically approved
List of papers
1. Screening to identify patients at risk: profiles of psychological risk factors for early intervention
Open this publication in new window or tab >>Screening to identify patients at risk: profiles of psychological risk factors for early intervention
2005 (English)In: The Clinical Journal of Pain, ISSN 0749-8047, E-ISSN 1536-5409, Vol. 21, no 1, p. 38-43Article in journal (Refereed) Published
Abstract [en]

There is a serious need to provide effective early interventions that prevent the development of persistent pain and disability. Identifying patients at risk for this development is an important step. Our aim was to explore whether distinct subgroups of individuals with similar response patterns on a screening questionnaire exist. Moreover, the objective was to then relate these groups to future outcomes, for example, sick leave as an impetus for developing tailored interventions that might better prevent chronic problems. A total of 363 patients seeking primary care for acute or subacute spinal pain completed the Orebro Musculoskeletal Pain Screening Questionnaire and were then followed to determine outcome. Cluster analysis was used to identify subgroups. Validity was tested using 3 methods including the split-half technique. The subgroups were compared prospectively on outcome measures obtained 1 year later. Using pain intensity, fear-avoidance beliefs, function, and mood, we found 4 distinct profiles: Fear-Avoidant, Distressed Fear-Avoidant, Low Risk, and Low Risk-Depressed Mood. These 4 subgroups were also robust in all 3 of the validity procedures. The 4 subgroups were clearly related to outcome. Although the low risk profiles had virtually no one developing long-term sick leave, the Fear-Avoidant profile had 35% and the Distressed Fear-Avoidant profile 62% developing long-term sick leave. Our results suggest that fear-avoidance and distress are important factors in the development of pain-related disability and may serve as a key for early identification. Providing interventions specific to the factors isolated in the profiles should enhance the prevention of persistent pain and disability.

National Category
Social Sciences Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:oru:diva-2814 (URN)15599130 (PubMedID)
Note
Discussion p. 69-72Available from: 2005-04-29 Created: 2005-04-29 Last updated: 2017-12-14Bibliographically approved
2. How does persistent pain develop?: An analysis of the relationship between psychological variables, pain and function across stages of chronicity
Open this publication in new window or tab >>How does persistent pain develop?: An analysis of the relationship between psychological variables, pain and function across stages of chronicity
2005 (English)In: Behaviour Research and Therapy, ISSN 0005-7967, E-ISSN 1873-622X, Vol. 43, no 11, p. 1495-1507Article in journal (Refereed) Published
Abstract [en]

The fear-avoidance model is an attempt to underscore the importance of cognitive and behavioral factors, in a chain of events linking pain to disability. However, it is not clear at what time point the psychological variables within the model begin to be prominent. The aim of this study was to investigate the role of these psychological variables in the development of a chronic musculoskeletal pain problem. Three stages of chronicity, defined by duration of pain, provided a proxy for the developmental process: <1 year (N=48), 1–3 years (N=47) and >3 years (N=89). Subjects completed questionnaires on fear of movement, catastrophizing, depression, pain and function. The results indicate that the relationship between fear of movement and function is moderated by the stage of chronicity. Regression analyses showed that fear of movement did not explain any variance in the group with pain duration <1 year. Fear of movement did explain variance in the groups with pain duration of 1–3 years and >3 years. This suggests that the time point in the development of a musculoskeletal pain problem might be an essential aspect of the importance of the relationship between psychological components and function.

Place, publisher, year, edition, pages
Oxford: Pergamon, 2005
National Category
Social Sciences Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:oru:diva-2815 (URN)10.1016/j.brat.2004.11.006 (DOI)16159591 (PubMedID)
Available from: 2005-04-29 Created: 2005-04-29 Last updated: 2017-12-14Bibliographically approved
3. Psychological processes underlying the development of a chronic pain problem: a prospective study of the relationship between profiles of psychological variables in the fear-avoidance model and disability
Open this publication in new window or tab >>Psychological processes underlying the development of a chronic pain problem: a prospective study of the relationship between profiles of psychological variables in the fear-avoidance model and disability
2006 (English)In: The Clinical Journal of Pain, ISSN 0749-8047, E-ISSN 1536-5409, Vol. 22, no 2, p. 160-166Article in journal (Refereed) Published
Abstract [en]

Objectives: Understanding the psychological processes that underlie the development of a chronic pain problem is important to improve prevention and treatment. The aim of this study was to test whether distinct profiles of variables within the fear-avoidance model could be identified and could be related to disability in a meaningful way.

Methods: In 81 persons with a musculoskeletal pain problem, cluster analysis was used to identify subgroups with similar patterns on fear and avoidance beliefs, catastrophizing, and depression. The clusters were examined cross-sectionally and prospectively on function, pain, health care usage, and sick leave.

Results: Five distinct profiles were found: pain-related fear, pain-related fear + depressed mood, medium pain-related fear, depressed mood, and low risk. These subgroups were clearly related to outcome. In contrast to the clusters medium pain-related fear and low risk, the majority of those classified in the clusters pain-related fear, pain-related fear + depressed mood, and depressed mood reported long-term sick leave during follow-up. The subjects in the clusters with high scores on the depression measure reported the highest percentage of health care usage during follow-up (70% in the pain-related fear + depressed mood group and 42% in the depressed mood group reported >10 health care visits).

Conclusions: Distinct profiles of psychological functioning could be extracted and meaningfully related to future disability. These profiles give support to the fear-avoidance model and underscore the need to address the psychological aspects of the pain experience early on.

Place, publisher, year, edition, pages
Lippincott Williams & Wilkins, 2006
National Category
Social Sciences Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:oru:diva-2816 (URN)16428950 (PubMedID)
Available from: 2005-04-29 Created: 2005-04-29 Last updated: 2018-02-20Bibliographically approved
4. Lowering fear-avoidance and enhancing function through exposure in vivo: a multiple baseline study across six patients with back pain
Open this publication in new window or tab >>Lowering fear-avoidance and enhancing function through exposure in vivo: a multiple baseline study across six patients with back pain
Show others...
2004 (English)In: Pain, ISSN 0304-3959, E-ISSN 1872-6623, Vol. 108, no 1-2, p. 8-16Article in journal (Refereed) Published
Abstract [en]

This study investigated the effects of an exposure in vivo treatment for chronic pain patients with high levels of fear and avoidance. The fear-avoidance model offers an enticing explanation of why some back pain patients develop persistent disability, stressing the role of catastrophic interpretations; largely fueled by beliefs and expectations that activity will cause injury and will worsen the pain problem. Recently, an exposure in vivo treatment was developed that aims to enhance function by directly addressing these fears and expectations. The purpose of this study was to describe the short-term, consequent effect of an exposure in vivo treatment. The study employed a multiple baseline design with six patients who were selected based on their high levels of fear and avoidance. The results demonstrated clear decreases in rated fear and avoidance beliefs while function increased substantially. These improvements were observed even though rated pain intensity actually decreased somewhat. Thus, the results replicate and extend the findings of previous studies to a new setting, with other therapists and a new research design. These results, together with the initial studies, provide a basis for pursuing and further developing the exposure technique and to test it in group designs with larger samples.

National Category
Social Sciences Psychology
Research subject
Psychology
Identifiers
urn:nbn:se:oru:diva-2817 (URN)10.1016/j.pain.2003.03.001 (DOI)
Available from: 2005-04-29 Created: 2005-04-29 Last updated: 2017-12-14Bibliographically approved

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