The Role of Self-Efficacy and Fear-Avoidance Beliefs in the Prediction of Disability

Both self-efficacy and fear-avoidance beliefs have been shown to be predictors of the level of disability in low back pain suffers. What is not clear from the literature, however, is whether the two constructs are differentially predictive of disability. The aim of this study was to investigate the relationship between pain self-efficacy and fear-avoidance beliefs and to determine whether they can explain unique variance in disability scores. One hundred and twenty-one people over the age of 18, suffering from chronic low back pain and receiving workers' compensation, completed the Pain Self-Efficacy Scale (PSEQ), the Fear Avoidance Beliefs questionnaire (FABQ), the Quebec Back Pain Disability Scale and a visual analogue scale for pain. The results show that, after controlling for pain, self-efficacy explained 24% of the variance in disability scores, and fear avoidance only a further 3.1%.     

A controlled evaluation of paraspinal EMG biofeedback in the treatment of chronic low back pain

Sixty-six chronic low back pain sufferers were randomly divided into three groups. Following individual assessments consisting of psychological questionnaires, pain monitoring, and measurement of paraspinal electromyogram (EMG), one group received paraspinal EMG biofeedback and another a placebo treatment. The third group received no intervention. Two further assessments were carried out on all groups immediately after treatment and at a 3-month follow-up. All groups showed significant reduction in pain, anxiety, depression, and paraspinal EMG following treatment and at follow-up, but there were no differences between groups. A regression analysis failed to identify subjects' characteristics that predicted positive outcome in the biofeedback group. However, high scores on the Evaluative scale of the McGill Pain Questionnaire and high hypnotizability were significant predictors of positive outcome for the placebo group. It is concluded that paraspinal EMG biofeedback is not a specific treatment for chronic low back pain in a nonhospitalized population.     

Task-related and person-related variables influence the effect of low back pain on anticipatory postural adjustments

BackgroundPeople with low back pain exhibit altered postural coordination that has been suggested as a target for treatment, but heterogeneous presentation has rendered it difficult to identify appropriate candidates and protocols for such treatments. This study evaluated the associations of task-related and person-related factors with the effect of low back pain on anticipatory postural adjustments.MethodsThirteen subjects with and 13 without low back pain performed seated, rapid arm flexion in self-initiated and cued conditions. Mixed-model ANOVA were used to evaluate group and condition effects on APA onset latencies of trunk muscles, arm-raise velocity, and pre-movement cortical potentials. These measures were evaluated for correlation with pain ratings, Fear Avoidance Beliefs Questionnaire scores, and Modified Oswestry Questionnaire scores.FindingsDelayed postural adjustments of subjects with low back pain were greater in the cued condition than in the self-initiated condition. The group with low back pain exhibited larger-amplitude cortical potentials than the group without pain, but also significantly slower arm-raise velocities. With arm-raise velocity as a covariate, the effect of low back pain remained significant for the latencies of postural adjustments but not for cortical potentials. Latencies of the postural adjustments significantly correlated with Oswestry and Fear Avoidance Beliefs scores.InterpretationDelayed postural adjustments with low back pain appear to be influenced by cueing of movement, pain-related disability and fear of activity. These results highlight the importance of subject characteristics, task condition, and task performance when comparing across studies or when developing treatment of people with low back pain.     

Use of verbal pain measurement in the detection of hidden psychological morbidity among low back pain patients with objective organic findings

Abstract

Patients with positive physical findings to explain low back pain arc believed lo belong to two organic subgroups. One group has organic disease alone: in the other, organic disease is accompanied by psychological disturbance. Separation of patients with medical findings into groups with varying levels of psychological disturbance is difficult, because emotional disturbance is often hidden. In this study, the pain report of 124 patients with organic findings alone, and 50 patients with organic and psychological findings was examined to determine whether pain measurement could he used to identify accurately patients belonging 10 the two groups. the pain groups differed in the use of 43 pain words from the Low Back Pain Symptom Check List. Using a set of weights derived From discriminant analysis. the 33 pain words predicted 99.2% of the patients with organic disease alone and 86.0% of the patients with organic disease and psychological disturbance. The results were replicated in a new sample of 140 patients. Cross-validation shrinkage in accuracy was 8.3%. The results of the two studies suggest that pain measurement may he a useful clinical indicator of psychological disturbance in patients with organic findings.     

The pain behavior scale: Modification and validation for outpatient use

The present study investigated the validity of an inpatient pain behavior rating scale modified for outpatient use. A series of 43 consecutive outpatients referred for evaluation of chronic pain was examined using the Pain Behavior Scale (PBS) and other psychometric instruments. Analyses revealed significantly higher Pain Behavior Scale scores for low back and multiple pain-site groups. The results also indicated a high degree of internal consistency of the scale. A multiple regression analysis, predicting observed pain behavior from reported pain behavior, indicated that decreased activity accounted for 32% of the variance in the PBS score. A similar regression for pain experience found that the pain level and the sensory scale score on the McGill Pain Questionnaire accounted for 39% of the PBS variance. Psychological characteristics including disease conviction, self-control, depression, and anxiety explained 45% of the variability in the PBS score. Thus, the scale is related to pain intensity, interference with activities, and a variety of psychological characteristics. The scale provides a measure of observable pain behavior that is also relatively independent of these clinical data sources. The Pain Behavior Scale as modified for outpatient use provides a brief index of pain behavior with potential use in the comprehensive evaluation of the pain patient.     

The Construing Of Pain: A Comparison Of Acute And Chronic Low Back Pain Patients Using The Repertory Grid Technique

Hypotheses derived from the literature on pain and on personal construct theory were tested using the repertory grid technique on samples of acute and chronic low back pain patients. Two main differences emerged between these groups: (a) Chronic pain patients showed a small but significant tendency to associate being in pain with being sensitive to others; and (b) chronic pain patients perceived significantly less anger around them. The two groups were then pooled to examine changes in construing with increasing pain duration. Two main trends were noted with increasing chronicity: (a) Pain patients perceived significantly less depression around them, with the construct depressed/not depressed becoming increasingly subordinate, and (b) pain was seen in increasingly less negative terms. The results are discussed with reference to the literature and suggestions are made for future research areas.     

The fear-avoidance model of exaggerated pain perception—II: Preliminary studies of coping strategies for pain

The personal history of pain and personal coping strategies for pain are two of the contributory factors in the Fear-Avoidance Model of exaggerated pain perception proposed by Lethem, Slade, Troup and Bentley (1983, this issue, pp. 401–408). In order to test this aspect of the hypothesis, a questionnaire was designed and has been completed by 165 students (93 female, 72 male) at the University of Liverpool.They were asked about the severity of externally-produced pain (e.g. fracture), of internally-produced pain (e.g. headache) and of back pain; about the strategies they adopted for coping with internallyproduced pain (e.g. did they ignore the pain and carry on—an active strategy—or did they go and rest—a passive strategy); and about the effects of back pain on each of 10 activities or postures (from ‘no effect’ to ‘had to stop completely’) in order to obtain an index of back-pain avoidance.Out of 165, 91 reported previous back pain (Back Pain group) and their average rating for the severity of externally-produced pain was significantly higher than for the No Back Pain group; but there were no differences between these two groups for their coping strategies for internally-produced pain. However, of the Back Pain group with two or more previous attacks, 35 gave a history indicating decreasingly severe attacks and 28, increasingly severe: the coping strategies of the latter group for internally-produced pain were significantly more passive. The ratings for severity of back pain correlated significantly with the indices for back-pain avoidance and with the ratings for severity of internally-produced pain.These findings are in line with the prediction that personal pain history and personal coping strategies are relevant to the Fear-Avoidance Model of exaggerated pain perception and may therefore influence the adoption of an avoidance or a confrontation response by the patient with chronic back pain.     

The role of additional information in the compliance,satisfaction, psychological,and emotion responses of non-surgical patients with low back pain: An exploratory investigation

Abstract

Noncompliance and the psychological and emotional states of patients with low back pain are major concerns for health professionals. The current study evaluated whether amount of information available to patients enhanced compliance to a medical regimen and whether it reduced negative emotions in patients with low back pain. Forty-five orthopaedic non-surgical patients with low back pain were randomly assigned to one of three information presentation conditions: 1) Standard, 2) Pre-examination, and 3) Post-examination. Patients were also separated by compensation and noncompensation within each information group. Patients completed questionnaires at their initial visit and at their follow-up which evaluated their: levels of compliance to a prescribed treatment program, psychological, and emotional states. Results indicated that some patients benefitted from receiving additional information as the Pre-examination and Post-examination groups demonstrated superior comprehension and recall as well as higher levels of compliance to a physical therapy program. In addition, compensation patients complained of more negative psychological and emotional behaviors in comparison to noncompensation patients. Implications of the research and future research considerations were discussed.     

The role of pain anxiety, coping, and pain self-efficacy in rheumatoid arthritis patient functioning

Anxiety about pain is increasingly recognized as one factor contributing to increased pain perception and pain behavior [McCracken, L. M., Faber S. D., & Janeck A. S. (1998) Pain-related anxiety predicts nonspecific physical complaints in persons with chronic pain. Behavior Research and Therapy, 36, 621-630; McCracken L., & Gross R. (1995). The pain anxiety symptoms scale (PASS) and the assessment of emotional responses to pain. Innovations in clinical practice: a source book, 14, 309-321]. To assess this emotional reaction to pain in chronic pain patients, McCracken, Zayfert and Gross [McCracken, L., Zayfert, C., & Gross, R. (1992). The Pain Anxiety Symptom Scale: development and validation of a scale to measure fear of pain. Pain, 50, 67-73] developed the Pain Anxiety Symptom Scale (PASS) composed of four subscales: Cognitive Anxiety, Fearful Appraisal, Escape Avoidance and Physiological Anxiety. The present study extended previous work by examining the relationship among pain anxiety dimensions, use of active and passive coping strategies and arthritis self-efficacy as predictors of functional status in 154 rheumatoid arthritis (RA) patients. Functional status was assessed using the Five-Factor Model of the Arthritis Impact Scale, 2nd ed., (AIMS2): Physical Functioning, Affective Experience, Symptoms, Social Interaction and Role Function. Hierarchical multiple regression analysis on each of the AIMS2 criterion variables showed that pain anxiety, pain and symptom self-efficacy, health status and coping strategies were able to explain between 9 and 38% of the variance in the five AIMS2 variables. The present results support the hypothesized role of pain anxiety along with previously established contributions of self-efficacy and coping strategies, in affecting physical, social, emotional and role functioning in chronic RA patients.     

Evidence of a disposition toward fearfulness and vulnerability to posttraumatic stress in dysfunctional pain patients

Few investigations have addressed whether patient subgroups derived using the Multiaxial Assessment of Pain (MAP) [Turk, D. C., & Rudy, T. E. (1987). Towards a comprehensive assessment of chronic pain patients. Behaviour Research and Therapy, 25, 237-249; Turk, D. C., & Rudy, T. E. (1988). Toward an empirically derived taxonomy of chronic pain patients: integration of psychological assessment data. Journal of Consulting and Clinical Psychology, 56, 233-238.] differ with regard to fear and avoidance. It has, however, been reported that dysfunctional patients exhibit more pain-specific fear and avoidance than patients classified as interpersonally distressed or minimizers/adaptive copers [Asmundson, G. J. G., Norton, G. R., & Allerdings, M. D. (1997). Fear and avoidance in dysfunctional chronic back pain patients. Pain, 69, 231-236.]. We attempted to extend these findings by examining two fear constructs that are receiving increased attention in the chronic pain literature-anxiety sensitivity and PTSD. The sample comprised 115 patients with chronic pain. Of these, 14 (12.2%) were classified as dysfunctional, 21 (18.3%) as interpersonally distressed and 47 (40.8%) as minimizers/adaptive copers. Between-group differences were observed on the fear of cognitive and emotional dyscontrol dimension of anxiety sensitivity, total and symptom cluster scores on the PTSD measure, and depression. No differences were observed for the fear of somatic sensations dimension of anxiety sensitivity or agoraphobia, social phobia, and blood/injury fears. Dysfunctional patients generally exhibited elevated scores relative to one or both of the other MAP subgroups on fear of cognitive and emotional dyscontrol, depressed affect, PTSD symptom total score and PTSD symptom cluster scores. As well, a substantial proportion of dysfunctional and interpersonally distressed patients were classified as having PTSD (71.4 and 42.9%, respectively) when compared to minimizers/adaptive copers (21.3%). These results suggest that MAP subgroups differ with regard to their propensity to be(come) fearful and in their likelihood of having PTSD. Theoretical and clinical implications are discussed.     

When Pain Does Not Heal: The Common Antecedents and Consequences of Chronic Social and Physical Pain

Researchers find that social and physical pain overlap in acute episodes. In this article, we hypothesize that social and physical pain overlap in chronic conditions as well. To support this hypothesis, we reviewed the literature and introduced the Integrated Chronic Pain Model (ICPM), which posits that chronic social and physical pain overlap in their psychological antecedents and consequences. Specifically, the ICPM proposes several common factors that play a role in the onset and maintenance of both social and physical chronic pain and indicates that both forms of pain persistently impair self-regulatory resources and threaten the same basic psychological needs.     

Problem-Solving Appraisal and Psychological Adjustment of Persons with Chronic Low-Back Pain

To examine the role of self-appraised problem-solving ability in the prediction of psychosocial impairment, depression, hopelessness, average pain unpleasantness, and current pain ratings among persons with chronic low-back pain. A second purpose was to enhance theoretical understanding of the mechanisms by which problem-solving appraisal influences adjustment. Correlational and regression procedures were used to test the hypothesized relations procedures between elements of self-appraised problem-solving ability and each criterion variable. Seventy-eight persons enrolled in an inpatient multidisciplinary chronic pain management program. The psychosocial subscale of the Sickness Impact Profile, the Beck Depression Inventory, the Beck Hopelessness Scale, the McGill Pain Questionnaire, and Visual Analogue Scales of Pain Sensory Intensity and Affective Response were the main outcome measures. After first controlling demographic characteristics, elements of self-appraised problem-solving ability assessed by the Problem-Solving Inventory were significantly predictive of depression, hopelessness, psychosocial impairment, and average pain unpleasantness (accounting for 20, 26, 29, and 11% of the respective variance in these constructs). Results indicate complex relations among the elements of problem-solving appraisal, suggesting that the Approach–Avoidance link to psychological adjustment was mediated by Problem-Solving Confidence. Comprehensive problem-solving interventions may be beneficial to persons with chronic pain     

Chronic pain and head injury following motor vehicle collisions: a double whammy or different sides of a coin

Chronic pain and head injury are common and burdensome sequelae of motor vehicle collisions. The aim of this study was to compare differences in physical injury and functional impairment, psychological distress and pain coping in head injured and non-head injured chronic pain persons subsequent to motor vehicle collisions. Two groups of 54 participants matched in terms of age, gender, and years of formal education underwent a psychological-legal assessment. As part of the assessment, participants completed the Multidimensional Pain Inventory, Sickness Impact Profile, Minnesota Multiphasic Personality Inventory-2, and Coping Strategies Questionnaires. Select scales from questionnaires were combined and underwent multivariate analyses of covariance to test the effects of pain sites at the time of psychological-legal assessment (low, high) and head injury status (head injured and non-head injured chronic pain). Overall, some differences between the two groups were noted but the results did not strongly support the hypothesis that head injured chronic pain participants have a greater physical or psychological burden than non-head injured chronic pain participants. The results suggest the import of assessing and managing pain sites and pain severity in persons injured in motor vehicle collisions.     

Psychological and social correlates of the back pain classification scale

The Back Pain Classification Scale (BPCS) identifies patients whose low back pain reflects a primary psychological disturbance. BPCS scores were related to the MMPI, State-Trait Anxiety Inventory, Multiple Affect Adjective Check List, and Social Readjustment Rating Scale scores; to distribution, intensity, and activities affecting pain; and to social characteristics of 116 patients. High scores on the BPCS (psychological disturbance) are associated with elevated MMPI profiles, and with more widely distributed and more intense pain. Stepwise multiple regression solutions indicate that the MMPI Hypochondriasis (Hs) scale accounts for 15.5% of the variance. No other variable accounts for as much as 3% of the variance. Scores on Hs relate primarily to words in the BPCS psychologically disturbed pole, supplying convergent validity to the BPCS. BPCS scores are unrelated to social characteristics, implying usefulness with the variety of patients seen for evaluation of low back pain.     

The Rorschach Concept Evaluation Technique

The Back Pain Classification Scale (BPCS). identifies patients whose low back pain reflects a primary psychological disturbance. BPCS scores were related to the MMPI, State-Trait Anxiety Inventory, Multiple Affect Adjective Check List, and Social Readjustment Rating Scale scores; to distribution, intensity, and activities affecting pain; and to social characteristics of t 16 patients. High scores on the BPCS (psychological disturbance) are associated with elevated MMPI profiles, and with more widely distributed and more intense pain. Stepwise multiple regression solutions indicate that the MMPI Hypochondriasis (Hs) scale accounts for 15.5% of the variance. No other variable accounts for as much as 3% of the variance. Scores on Hs relate primarily to words in the BPCS psychologically disturbed pole, supplying convergent validity to the BPCS. BPCS scores are unrelated to social characteristics, implying usefulness with the variety of patients seen for evaluation of low back pain.     

Anxiety sensitivity in the prediction of pain-related fear and anxiety in a heterogeneous chronic pain population

The present study evaluated anxiety sensitivity, along with depression and pain severity, as predictors of pain-related fear and anxiety in a heterogeneous chronic pain population (n=68). The results indicated that the global anxiety sensitivity factor, as indexed by the Anxiety Sensitivity Index (ASI: Reiss, Peterson, Gursky & McNally, 1986: Reiss, S., Peterson, R. A., Gursky, M. & McNally, R. J. (1986). Anxiety, sensitivity, anxiety frequency, and the prediction of fearfulness. Behaviour Research and Therapy, 24, 1-8) total score, was a better predictor of fear of and anxiety about pain relative to the other relevant variables. Additionally, the physical concerns subscale of the ASI was a better predictor of pain-related fear dimensions characterized by high degrees of physiological symptoms and behavioral activation on both the Fear of Pain Questionnaire-III (FPQ-III; McNeil & Rainwater, 1998: McNeil, D. W. & Rainwater, A. J. (1998). Development of the Fear of Pain Questionnaire-III. Journal of Behavioral Medicine.) and Pain Anxiety Symptoms Scale (PASS; McCracken, Zayfert & Gross, 1992: McCracken, L. M., Zayfert, C. & Gross, R. T. (1992). The Pain Anxiety Symptoms Scale: Development and validation of a scale to measure fear of pain. Pain, 50, 67-73). In a related way, the ASI psychological concerns subscale was a better predictor of pain-related anxiety dimensions characterized by cognitive symptoms of anxiety. Overall, these findings reiterate the importance of anxiety sensitivity in understanding pain-related fear and anxiety, and suggest anxious and fearful responding can be predicted more accurately with higher levels of correspondence between a particular anxiety sensitivity domain and events that closely match that fear.     

Self-conscious emotions in patients suffering from chronic musculoskeletal pain: A brief report

Objective: The role of self-conscious emotions (SCEs) including shame, guilt, humiliation and embarrassment are of increasing interest within health. Yet, little is known about SCEs in the experience of chronic pain. This study explored prevalence and experience of SCEs in chronic pain patients compared to controls and assessed the relationship between SCEs and disability in pain patients.

Design and measures: Questionnaire assessment comparing musculoskeletal pain patients (n = 64) and pain-free control participants (n = 63). Pain was assessed using the McGill Pain Questionnaire; disability, using the Roland–Morris Disability Questionnaire; and six SCEs derived from three measures (i) Test of Self-Conscious Affect-3 yielding subscales of shame, guilt, externalisation and detachment (ii) The Brief Fear of Negative Evaluation Scale and (iii) The Pain Self-Perception Scale assessing mental defeat.

Results: Significantly greater levels of shame, guilt, fear of negative evaluation and mental defeat were observed in chronic pain patients compared to controls. In the pain group, SCE variables significantly predicted affective pain intensity; only mental defeat was significantly related to disability.

Conclusion: Findings highlight the prevalence of negative SCEs and their importance in assessment and management of chronic pain. The role of mood in this relationship is yet to be explored.     

Follow-up results of a cognitive-behavioural treatment for chronic pain in a primary care setting

Abstract

An outpatient cognitive-behavioural treatment programme for pain control was administered to chronic pain patients in three primary care practices with a medical psychologist as a group therapist. The patients suffered from headaches, migraines, cervical pain, shoulder-arm pain, and low back pain. A matched sample of patients with the same disorders served as a waiting-list control group. The programme consisted of training in progressive muscle relaxation, several attention related techniques, and cognitive restructuring as well as reinforcing non-pain behaviour, and aimed at an improvement of self-control strategies. At the six month follow-up, the treated subjects showed improvements in their average scores of anxiety, depression and bodily symptoms compared with the untreated controls. Pain intensity was reduced by 34% in those subjects (9 out of 25) who were most adherent to the treatment regimen. Our results indicate a long-term improvement in well-being as a consequence of the treatment. This was confirmed by the ratings of the physicians and by the reduced number of patient-physician contacts three months post treatment as compared to the controls. Treatment adherence seems to be a most important agent in maintaining long-term reductions of pain intensity.     

Relationship between the Millon Behavioral Health Inventory and the minnesota multiphasic personality inventory (MMPI) in low-back pain patients

The Millon Behavioral Health Inventory (MBHI) is being used with increasing frequency for the assessment of chronic pain, although there is a relative lack of evidence as to its utility, and prior studies have not examined low back pain. This investigation compared the MBHI to the MMPI in a sample of low-back pain patients and analyzed subgroups of pain patients based upon their MBHI responses. Subjects were 60 patients who had been admitted to outpatient multidisciplinary pain clinics of two Chicago-area hospitals. Patients completed both the MMPI and the MBHI and provided demographic information. Results of correlational analyses indicated strong relationships between the MBHI psychogenic attitude, psychosomatic correlate, and prognostic index scales and the validity scales of the MMPI. The MBHI Pain Treatment Responsivity scale (PP) correlated with 16 of the other 19 MBHI scales. PP did not demonstrate specificity with low back pain patients. The results of both the scale comparisons and the exploratory two-group cluster subgroup analysis support the notion that responses to the MBHI are largely affected by the respondent's tendency to deny psychopathology or to admit emotional distress.