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The Key Role of Pain Catastrophizing in the Disability of Patients with Acute Back Pain

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Abstract

Purpose

This study investigated the role of anxiety sensitivity, resilience, pain catastrophizing, depression, pain fear-avoidance beliefs, and pain intensity in patients with acute back pain-related disability.

Method

Two hundred and thirty-two patients with acute back pain completed questionnaires on anxiety sensitivity, resilience, pain catastrophizing, fear-avoidance beliefs, depression, pain intensity, and disability.

Results

A structural equation modelling analysis revealed that anxiety sensitivity was associated with pain catastrophizing, and resilience was associated with lower levels of depression. Pain catastrophizing was positively associated with fear-avoidance beliefs and pain intensity. Depression was associated with fear-avoidance beliefs, but was not associated with pain intensity. Finally, catastrophizing, fear-avoidance beliefs, and pain intensity were positively and significantly associated with acute back pain-related disability.

Conclusion

Although fear-avoidance beliefs and pain intensity were associated with disability, the results showed that pain catastrophizing was a central variable in the pain experience and had significant direct associations with disability when pain was acute. Anxiety sensitivity appeared to be an important antecedent of catastrophizing, whereas the influence of resilience on the acute back pain experience was limited to its relationship with depression.

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References

  1. Asmundson GJG, Norton PJ, Norton GR. Beyond pain: the role of fear and avoidance in chronicity. Clin Psy Rev. 1999;19:97–119.

    Article  CAS  Google Scholar 

  2. Norton PJ, Asmundson GJG. Amending the fear-avoidance model of chronic pain: what is the role of physiological arousal? Behav Ther. 2003;34:17–30.

    Article  Google Scholar 

  3. Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317–32.

    Article  CAS  PubMed  Google Scholar 

  4. Boersma K, Linton SJ. Expectancy, fear and pain in the prediction of chronic pain and disability: a prospective analysis. Eur J Pain. 2005;10:551–7.

    Article  PubMed  Google Scholar 

  5. Lethem J, Slade PD, Troup JDG, Bentley G. Outline of a fear-avoidance model of exaggerated pain perceptions. Behav Res Ther. 1983;21:401–8.

    Article  CAS  PubMed  Google Scholar 

  6. Vlaeyen JWS, Kole-Snijders AM, Boeren RG, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62:363–72.

    Article  CAS  PubMed  Google Scholar 

  7. Reiss S, McNally RJ. Expectancy model of fear. In: Reiss S, Bootzin RR, editors. Theoretical issues in behaviour therapy. San Diego: Academic Press; 1985. p. 107–21.

    Google Scholar 

  8. Asmundson GJG, Norton PJ, Vlaeyen JWS. Fear-avoidance models of chronic pain: an overview. In: Asmundson GJG, Vlaeyen JWS, Crombez G, editors. Understanding and treating fear of pain. Oxford: Oxford University Press; 2004. p. 3–24.

    Google Scholar 

  9. Gheldof ELM, Crombez G, Van den Bussche E, Vinck J, Van Nieuwenhuyse A, Moens G, Mairiaux P, Vlaeyen JWS. Pain-related fear predicts disability, but not pain severity: a path analytic approach of the fear-avoidance model. Eur J Pain. 2010;14:870.e1–9.

    Article  Google Scholar 

  10. Fritz JM, George SZ, Delitto A. The role of fear-avoidance beliefs in acute low back pain: relationships with current and future disability and work status. Pain. 2001;94:7–15.

    Article  CAS  PubMed  Google Scholar 

  11. Klenerman L, Slade PD, Stanley IM, Pennie B, Reilly JP, Atchison LE, Troup JD, Rose MJ. The prediction of chronicity in patients with an acute attack of low back pain in a general practice setting. Spine. 1995;20:478–84.

    Article  CAS  PubMed  Google Scholar 

  12. Swinkels-Meewisse EJ, Roelofs J, Verbeek AL, Oostendorp RA, Vlaeyen JWS. Fear of movement/(re) injury, disability and participation in acute low back pain. Pain. 2003;105:371–9.

    Article  PubMed  Google Scholar 

  13. Grotle M, Vollestad NK, Veierod MB, Brox JI. Fear-avoidance beliefs and distress in relation to disability in acute and chronic low back pain. Pain. 2004;112(3):343–52.

    Article  PubMed  Google Scholar 

  14. Buer N, Linton SJ. Fear-avoidance beliefs and catastrophizing: occurrence and risk factor in back pain and ADL in the general population. Pain. 2002;99(3):485–91.

    Article  PubMed  Google Scholar 

  15. Picavet HS, Vlaeyen JW, Schouten JS. Pain catastrophizing and kinesiophobia: predictors of chronic low back pain. Am J Epidemiol. 2002;156(11):1028–34.

    Article  PubMed  Google Scholar 

  16. Citero VD, Levenson JL, McClish DK, Bovbjerg VE, Cole PL, Dahman BA, Penberthy LT, Aisiku IP, Roseff SD, Smith WR. The role of catastrophizing in sickle cell disease—the PiSCES project. Pain. 2007;133:39–6.

    Article  Google Scholar 

  17. Edwards RR, Cahalan C, Mensing G, Smith M, Haythornthwaite JA. Pain, catastrophizing, and depression in the rheumatic diseases. Nat Rev Rheumatol. 2011;7:216–24.

    Article  CAS  PubMed  Google Scholar 

  18. de Boer MJ, Struys MMRF, Versteegen GJ. Pain-related catastrophizing in pain patients and people with pain in the general population. Eur J Pain. 2012;16:1044–52.

    Article  PubMed  Google Scholar 

  19. Epping-Jordan JE, Wahlgren DR, Williams RA, Pruitt SD, Slater MA, Patterson TL, et al. Transition to chronic pain in men with low back pain: predictive relationships among pain intensity, disability, and depressive symptoms. Health Psychol. 1998;17(5):421–7.

    Article  CAS  PubMed  Google Scholar 

  20. Linton SJA. Review of psychological risk factors in back and neck pain. Spine. 2000;25:1148–56.

    Article  CAS  PubMed  Google Scholar 

  21. Zale EL, Lange KL, Fields SA, Ditre W. The relationship between pain-related fear and disability: a meta-analysis. J Pain. 2013;14:1019–30.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Asmundson GJG, Parkerson HA, Petter M, Noel M. What is the role of fear and escape/avoidance in chronic pain? Models, structural analysis and future directions. Pain Manage. 2012;2:295–303.

    Article  Google Scholar 

  23. Wideman TH, Sullivan MJL. Differential predictors of the long-term levels of pain intensity, work disability, healthcare use, and medication use in a sample of workers’ compensation claimants. Pain. 2011;152:376–83.

    Article  PubMed  Google Scholar 

  24. Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as prognostic factors for outcome in patients with nonspecific low back pain: a systematic review. Spine J. 2014;14:816–36.

    Article  PubMed  Google Scholar 

  25. Esteve R, Ramírez-Maestre C, López-Martínez AE. Experiential avoidance and anxiety sensitivity as dispositional variables and their relationship to the adjustment to chronic pain. Eur J Pain. 2012;16:718–26.

    Article  CAS  PubMed  Google Scholar 

  26. Evers AWM, Zautra A, Thieme K. Stress and resilience in rheumatic diseases: a review and glimpse into the future. Nat Rev Rheumatol. 2011;7(7):409–15.

    Article  PubMed  Google Scholar 

  27. Peters ML, Vancleef LMG. The role of personality traits in pain perception and disability. Reviews in analgesia. 2008;10:11–22.

  28. Ramírez-Maestre C, Esteve R, López A. The path to capacity: resilience and spinal chronic pain. Spine. 2012;37:251–8.

    Article  Google Scholar 

  29. Velasco Furlong LV, Zautra A, Puente CP, López-López A, Valero PB. Cognitive-affective assets and vulnerabilities: two factors influencing adaptation to fibromyalgia. Psychol Health. 2010;25:197–212.

    Article  Google Scholar 

  30. Yeung EWH, Arewasikporn A, Zautra AJ. Resilience and chronic pain. J Soc Clin Psychol. 2012;31(6):593–617.

    Article  Google Scholar 

  31. Davydov DM, Steward R, Ritchie K, Chaudieu I. Resilience and mental health. Clin Psychol Rev. 2010;30:479–95.

    Article  PubMed  Google Scholar 

  32. Friborg O, Hjemdal O, Rosenvinge JH, Martinussen M, Aslaksen PM, Flaten MA. Resilience as a moderator of pain and stress. J Psychosom Res. 2006;61:213–9.

    Article  PubMed  Google Scholar 

  33. Smith BW, Tooley EM, Montague EQ, Robinson AE, Cosper CJ, Mullins PG. The role of resilience and purpose in life in habituation to heat and cold pain. J Pain. 2009;10:493–500.

    Article  PubMed  Google Scholar 

  34. Evers AWM, Zautra A, Thieme K. Stress and resilience in rheumatic diseases: a review and glimpse into the future. Nat Rev Rheumatol. 2011;7:409–15.

    Article  PubMed  Google Scholar 

  35. Yeung EWH, Arewasikporn A, Zautra AJ. Resilience and chronic pain. J Soc Clin Psychol. 2012;31:593–617.

    Article  Google Scholar 

  36. Pincus T, Vogel S, Burton AK, Santos R, Field AP. Fear-avoidance and prognosis of back pain: a systematic review and synthesis of current evidence. Arthritis Rheum. 2006;54:3999–4010.

    Article  PubMed  Google Scholar 

  37. Pincus T, Smeets RJEM, Simmonds MJ, Sullivan MJL. The fear avoidance model disentangled: improving the clinical utility of the fear avoidance model. Clin J Pain. 2010;26:739–46.

    Article  PubMed  Google Scholar 

  38. Kamper SJ, Maher CG, Menezes Costa Lda C, JH MA, JM H, Sterling M. Does fear of movement mediate the relationship between pain intensity and disability in patients following whiplash injury? A prospective longitudinal study. Pain. 2012;153:113–9.

    Article  PubMed  Google Scholar 

  39. Sullivan M, Tanzer M, Stanish W, Fallaha M, Keefe FJ, Simmonds M, Dunbar M. Psychological determinants of problematic outcomes following total knee arthroplasty. Pain. 2009;143:123–9.

    Article  PubMed  Google Scholar 

  40. Ramírez-Maestre C, Esteve MR, López AE. Fear-avoidance, pain acceptance and adjustment to chronic pain: a cross-sectional study on a sample of 686 patients with chronic spinal pain. Ann Behav Med. 2014;48:402–10.

    Article  PubMed  Google Scholar 

  41. Peterson RA, Reiss S. Anxiety sensitivity index Mannual. 2nd ed. Worthington, OH: International Diagnostic Systems; 1992.

    Google Scholar 

  42. Sandín B, Chorot P, McNally RJ. Validation of the Spanish version of the anxiety sensitivity index in a clinical sample. Behav Res Ther. 1996;134:283–90.

    Article  Google Scholar 

  43. Wagnild GM, Young HM. Development and psychometric evaluation of the resilience scale. J Nurs Meas. 1993;1:165–78.

    CAS  PubMed  Google Scholar 

  44. Ruíz-Párraga G, López-Martínez A, Gómez-Pérez L. Factor structure and psychometric properties of the resilience scale in a Spanish chronic musculoskeletal pain sample. J Pain. 2012;13:1090–8.

    Article  PubMed  Google Scholar 

  45. Sullivan MJL, Bishop SC, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess. 1995;7:524–32.

    Article  Google Scholar 

  46. Muñoz M, Esteve R. Reports of memory functioning by chronic pain patients. Clin J Pain. 2005;21:287–91.

    Article  PubMed  Google Scholar 

  47. Waddell G, Newton M, Henderson J, Somerville D, Main CJA. Fear-Avoidance Beliefes Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993;52:157–68.

    Article  CAS  PubMed  Google Scholar 

  48. Kovacs FM, Muriel A, Medina JM, Abraira V, Castillo-Sánchez MD, Olabe-Jaúregui J. Psychometric characteristics of the Spanish version of the FABQ questionnaire. Spine. 2006;31:104–10.

    Article  PubMed  Google Scholar 

  49. Snaith RP, Zigmond AS. The hospital anxiety and depression scale manual. Windsor, UK: NFER-Nelson; 1994.

    Google Scholar 

  50. Quintana JM, Padierna A, Esteban C, Arostegui I, Bilbao A, Ruiz I. Evaluation of the psychometric characteristics of the Spanish version of the Hospital Anxiety and Depression Scale. Act Psych Scan. 2003;107:216–21.

    Article  CAS  Google Scholar 

  51. Jensen MP, Turner P, Romano JM, Fischer LD. Comparative reliability and validity of chronic pain intensity measures. Pain. 1999;83:157–62.

    Article  CAS  PubMed  Google Scholar 

  52. Roland M, Morris RA. Study of the natural history of back pain. Part I. Spine. 1983;8:141–4.

    Article  CAS  PubMed  Google Scholar 

  53. Kovacs FM, Llobera J, Gil del Real MT, Abraira V, Gestoso M, Fernández G. Grupo Kovacs de Atención Primaria. Validation of the Spanish version of the Roland Morris questionnaire. Spine. 2002;27:538–42.

    Article  PubMed  Google Scholar 

  54. Bollen KA, Long JS. Introduction. In: Bollen KA, Long JS, editors. Testing structural equation models. Newbury Park, CA: Sage; 1993.

    Google Scholar 

  55. Bentler PM. EQS 6 Structural Equations Program Manual. Encino, CA: Multivariate Software, Inc.; 2006.

    Google Scholar 

  56. Kline RB. Principles and practice of structural equation modeling. 3rd ed. NY: Guilford Press; 2005.

    Google Scholar 

  57. Bentler PM, Bonnet DG. Significance tests and goodness of fit in the analysis of covariance structures. Psychol Bull. 1980;88:588–606.

    Article  Google Scholar 

  58. Hu L, Bentler PM. Fit indices in covariance structure modelling: sensitivity to underparameterized model misspecification. Psychol Meth. 1998;3:424–53.

    Article  Google Scholar 

  59. Hu L, Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Modelling. 1999;6:1–55.

    Article  Google Scholar 

  60. Cohen JW. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988.

    Google Scholar 

  61. Sullivan MJL, Thorn BE, Haythornthwaite JA, Keefe F, Martin M, Bradley LA, Lefebvre JC. Theoretical perspectives on the relation between catastrophizing and pain. Clin J Pain. 2001;17:52–64.

    Article  CAS  PubMed  Google Scholar 

  62. Leeuw M, Goossens MEJB, Linton SJ, Crombez G, Boersma K, Vlaeyen JWS. The fear avoidance model of musculoskeletal pain: current state of scientific evidence. Behav Med. 2007;30:77–94.

    Article  Google Scholar 

  63. Karoly P, Ruehlman LS. Psychological resilience and its correlates in chronic pain: finding from a national community sample. Pain. 2006;123:90–7.

    Article  PubMed  Google Scholar 

  64. Turk DCA. Diathesis-stress model of chronic pain and disability following traumatic injury. Pain Res Manag. 2002;7:9–19.

    Article  PubMed  Google Scholar 

  65. Crombez G, Eccleston C, Van Damme E, Vlaeyen JWS, Karoly P. Fear-avoidance model of chronic pain. The next generation. Clin J Pain. 2012;28:475–83.

    Article  PubMed  Google Scholar 

  66. Kapoor BE, Thorn O, Bandy KL, Clements KL. Pain referents used to respond to the pain catastrophizing scale. Eur J Pain. 2015;19:400–7.

    Article  CAS  PubMed  Google Scholar 

  67. Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother. 2009;9:745–58.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Campbell CM, Kronfli T, Buenaver LF, Smith MT, Berna C, Haythornthwaite JA, Edwards RR. Situational versus dispositional measurement of catastrophizing: associations with pain responses in multiple samples. J Pain. 2010;11:443–53.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Campbell CM, Quartana PJ, Buenaver LF, Haythornthwaite JA, Edwards RR. Changes in situation-specific pain catastrophizing precede changes in pain report during capsaicin pain: a cross-lagged panel analysis among healthy, pain-free participants. J Pain. 2010;11:876–84.

    Article  PubMed  Google Scholar 

  70. Khan RS, Ahmed K, Blakeway E, Skapinakis P, Nihoyannopoulos L, Macleod K, Sevdalis N, Ashrafian H, Platt M, Darzi A, Athanasiou T. Catastrophizing: a predictive factor for postoperative pain. Am J Surg. 2011;201:122–31.

    Article  PubMed  Google Scholar 

  71. Mankovsky T, Lynch ME, Clark AJ, Sawynok J, Sullivan MJL. Pain catastrophizing predicts poor response to topical analgesics in patients with neuropathic pain. Pain Res Manag. 2012;17:10–4.

    Article  PubMed  PubMed Central  Google Scholar 

  72. Gheldof EL, Vinck J, Vlaeyen JWS, Hidding A, Crombez G. The differential role of pain, work characteristics and pain-related fear in explaining back pain and sick leave in occupational settings. Pain. 2005;113:71–81.

    Article  PubMed  Google Scholar 

  73. Gheldof ELM, Vinck J, Van den Bussche E, Vlaeyen JWS, Hidding A, Crombez G. Pain and pain-related fear are associated with functional and social disability in an occupational setting: evidence of mediation by pain-related fear. Eur J Pain. 2006;10:513–25.

    Article  PubMed  Google Scholar 

  74. Truchon M, Fillion L. Biopsychosocial determinants of chronic disability and low-back pain: a review. J Occup Rehabil. 2000;10(2):117–42.

    Article  Google Scholar 

  75. Waddell G, Main CJ. Beliefs about back pain. In: Waddell G, editor. The back pain revolution. Edinburgh: Churchill Livingstone; 1998. pp. 187–202.

  76. Burton AK, Tillotson KM, Main CJ, Hollis S. Psychosocial predictors of outcome in acute and subchronic low back trouble. Spine. 1995;20(6):722–8.

    Article  CAS  PubMed  Google Scholar 

  77. Williams RA, Pruitt SD, Doctor JN, Epping-Jordan JE, Wahlgren DR, Grant I, et al. The contribution of job satisfaction to the transition from acute to chronic low back pain. Arch Phys Med Rehabil. 1998;79(4):366–74.

    Article  CAS  PubMed  Google Scholar 

  78. Linton SJ, Hallden K. Can we screen for problematic back pain? A screening questionnaire for predicting outcome in acute and subacute back pain. Clin J Pain. 1998;14(3):209–15.

    Article  CAS  PubMed  Google Scholar 

  79. Gatchel RJA. Biopsychosocial overview of pretreatment screening of patients with pain. Clin J Pain. 2001;17(3):192–9.

    Article  CAS  PubMed  Google Scholar 

  80. Linton SJ. Occupational psychological factors increase the risk for back pain: a systematic review. J Occup Rehabil. 2001;11(1):53–66.

    Article  CAS  PubMed  Google Scholar 

  81. Pincus T, Burton AK, Vogel S, Field APA. Systematic review of psychological risk factors for chronicity/disability in prospective cohorts of low back pain. Spine. 2002;27:109–20.

    Article  Google Scholar 

  82. Keefe FJ, Rumble ME, Scipio CD, Giordano LA, Perri LM. Psychological aspects of persistent pain: current state of the science. J Pain. 2004;5:195–211.

    Article  PubMed  Google Scholar 

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Acknowledgments

This research was supported by grants from the Spanish Ministry of Science and Innovation (PSI2008-01803/PSIC) and the Andalusian Regional Government (HUM-566; P07-SEJ-3067).

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Ramírez-Maestre, C., Esteve, R., Ruiz-Párraga, G. et al. The Key Role of Pain Catastrophizing in the Disability of Patients with Acute Back Pain. Int.J. Behav. Med. 24, 239–248 (2017). https://doi.org/10.1007/s12529-016-9600-9

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