Skip to main content

Advertisement

SpringerLink
Log in

Cortisol Awakening Response and Pain-Related Fear-Avoidance Versus Endurance in Patients Six Months After Lumbar Disc Surgery

  • Published:
Applied Psychophysiology and Biofeedback Aims and scope Submit manuscript

Abstract

Recent research indicates that stress-induced, prolonged deviations in basal adrenocortical activity might contribute to ongoing/recurrent pain following lumbar disc surgery. Further, fear-avoidance and endurance responses to pain (FAR and ER) are regarded as important risk factors for pain after surgery. In patients with non-specific low back pain, FAR appear to possibly increase pain-related arousal, whereas ER may have an arousal-lowering effect, indicated by adrenocortical activity. The current study explores the relationship between basal adrenocortical activity and FAR and ER. Thirty-six patients 6 months after lumbar disc surgery participated. Basal adrenocortical activity was assessed through the cortisol awakening response (CAR), using salivary samples collected on two consecutive days. FAR and ER were estimated using questionnaires. While the ER variables pain-persistence behavior and positive mood despite pain showed negative associations with the CAR, the FAR variables fear-avoidance beliefs and avoidance of social activity were positively correlated with it. Additionally, higher CAR levels were found in patients with high versus patients with low fear-avoidance beliefs and, conversely, in patients with low versus high positive mood and pain persistence. These results indicate that FAR may increase the individuals’ level of pain-related stress among patients after disc surgery, while ER may lower it.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  • Adam, E. K., Hawkley, L. C., Kudielka, B. M., & Cacioppo, J. T. (2006). Day-to-day dynamics of experience-cortisol associations in a population-based sample of older adults. Proceedings of the National academy of Sciences of the United States of America, 103, 17058–17063.

    Article  PubMed  Google Scholar 

  • Al’Absi, M., Petersen, K. L., & Wittmers, L. E. (2002). Adrenocortical and hemodynamic predictors of pain perception in men and women. Pain, 96, 19–204.

    Google Scholar 

  • Alaranta, H., Hurme, M., Lahtela, K., & Hyyppä, M. T. (1983). Prolactin and cortsol in cerebrospinal fluid: sex-related associations with clinical and psychological characteristics of patients with low back pain. Psychoneuroendocrinology, 8, 333–341.

    Article  PubMed  Google Scholar 

  • Anton, F. (2009). Chronic stress and pain: A plea for a concerted research program. Pain, 143, 163–164.

    Article  PubMed  Google Scholar 

  • Bousema, E. J., Verbunt, J. A., Seelen, H. A. M., Vlaeyen, J. W. S., & Knottnerus, J. A. (2007). Disuse and physical deconditioning in the first year after the onset of pain. Pain, 130, 279–286.

    Article  PubMed  Google Scholar 

  • Chida, Y., & Steptoe, A. (2009). Cortisol awakening response and psychosocial factors: a systematic review and meta-analysis. Biological Psychology, 80, 265–278.

    Article  PubMed  Google Scholar 

  • Clauw, D. J., & Ablin, J. N. (2009). The relationship between “stress” and pain: Lessons learned from fibromyalgia and related conditions. In J. Castro-Lopes (Ed.), Current topics of pain: 12th world congress on pain (pp. 245–270). Seattle, WA: IASP Press.

    Google Scholar 

  • den Boer, J. J., Oostendorp, R. A. B., Beems, T., Munneke, M., Oerlemans, M., & Evers, A. W. M. (2006). A systematic review of bio-psychosocial risk factors for an unfavourable outcome after lumbar disc surgery. European Spine Journal, 15, 527–536.

    Article  Google Scholar 

  • Dickerson, S. S., & Kemeny, M. E. (2004). Acute stressors and cortisol responses: A theoretical integration and synthesis of laboratory research. Psychological Bulletin, 130, 355–391.

    Article  PubMed  Google Scholar 

  • Dressendörfer, R. A., Kirschbaum, C., Rohde, W., Stahl, F., & Strasburger, C. J. (1992). Synthesis of a cortisol-biotin conjugate and evaluation as a tracer in an immunoassay for salivary cortisol measurement. The Journal of Steroid Biochemistry and Molecular Biology, 43, 683–692.

    Article  PubMed  Google Scholar 

  • Edwards, R. R., Klick, B., Buenaver, L., Max, M. B., Haythornthwaite, J. A., Keller, R. B., et al. (2007). Symptoms of distress as prospective predictors of pain-related sciatica treatment outcomes. Pain, 130, 47–55.

    Article  PubMed  Google Scholar 

  • Fairbanks, J. C., Couper, J., Davies, J. B., & O’Brien, J. P. (1980). The Oswestry low back pain disability questionnaire. Physiotherapy, 66, 271–273.

    Google Scholar 

  • Fries, E., Hesse, J., Hellhammer, J., & Hellhammer, D. H. (2005). A new view on hypocortisolism. Psychoneuroendocrinology, 30, 1010–1016.

    Article  PubMed  Google Scholar 

  • Gatchel, R. J., Peng, Y. B., Peters, M. L., Fuchs, P. N., & Turk, D. C. (2007). The biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133, 581–624.

    Article  PubMed  Google Scholar 

  • Geiss, A., Rohleder, N., Kirschbaum, C., Steinbach, K., Bauer, H. W., & Anton, F. (2005). Predicting the failure of disc surgery by a hypofunctional HPA axis: Evidence from a prospective study on patients undergoing disc surgery. Pain, 114, 104–117.

    Article  PubMed  Google Scholar 

  • Geiss, A., Varadi, E., Steinbach, K., Bauer, H. W., & Anton, F. (1997). Psychoneuroimmunological correlates of persisting sciatic pain in patients who underwent discectomy. Neuroscience Letters, 237, 65–68.

    Article  PubMed  Google Scholar 

  • Grebner, M., Breme, K., Rothoerl, R., Woertgen, C., Hartmann, A., & Thomé, C. (1999). Coping and convalescence course after lumbar disc operations. Der Schmerz, 13, 19–30.

    Article  PubMed  Google Scholar 

  • Griep, E. N., Boersma, J. W., Lentjes, E. G. W. M., Prins, A. P. A., van der Korst, J. K., & de Kloet, E. R. (1998). Function of the hypothalamic-pituitary-adrenal axis in patients with fibromyalgia and low back pain. The Journal of Rheumatology, 25, 1374–1381.

    PubMed  Google Scholar 

  • Hasenbring, M. I., Hallner, D., & Rusu, A. C. (2009). Fear-avoidance and endurance-related responses to pain: Development and validation of the avoidance-endurance questionnaire (AEQ). European Journal of Pain, 13, 620–628.

    Article  PubMed  Google Scholar 

  • Hasenbring, M., Marienfeld, G., Kuhlendal, D., & Soyka, D. (1994). Risk factors of chronicity in lumbar disc patients. A prospective investigation of biologic, psychologic, and social predictors of therapy outcome. Spine, 19, 2759–2765.

    Article  PubMed  Google Scholar 

  • Hasenbring, M. I., Plaas, H., Fischbein, B., & Willburger, R. (2006). The relationship between activity and pain in patients 6 months after lumbar disc surgery: Do pain-related coping modes act as moderator variables? European Journal of Pain, 10, 701–709.

    Article  PubMed  Google Scholar 

  • Hasenbring, M. I., & Verbunt, J. A. (2010). Fear-avoidance and endurance-related responses to pain: new models of behaviour and their consequences for clinical practice. The Clinical Journal of Pain, 26, 747–753.

    Article  PubMed  Google Scholar 

  • Haythornthwaite, J. A., Menefee, L. A., Heinberg, L. J., & Clark, M. R. (1998). Pain coping strategies predict perceived control over pain. Pain, 77, 33–39.

    Article  PubMed  Google Scholar 

  • Heim, C., Ehlert, U., & Hellhammer, D. H. (2000). The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders. Psychoneuroendocrinology, 25, 1–35.

    Article  PubMed  Google Scholar 

  • Hellhammer, D. H., & Wade, S. (1993). Endocrine correlates of stress vulnerability. Psychotherapy and Psychosomatics, 60, 8–17.

    Article  PubMed  Google Scholar 

  • Johansson, A. C., Linton, S. J., Rosenblad, A., Bergkvist, L., & Nilsson, O. (2010). A prospective study of cognitive behavioural factors as predictors of pain, disability and quality of life one year after lumbar disc surgery. Disability and Rehabilitation, 32, 521–529.

    Article  PubMed  Google Scholar 

  • Kahn, J. P., Rubinow, D. R., Davis, C. L., Kling, M., & Post, R. M. (1988). Salivary cortisol: a practical method for evaluation of adrenal function. Biological Psychiatry, 23, 335–349.

    Article  PubMed  Google Scholar 

  • Kirschbaum, C., & Hellhammer, D. H. (2000). Salivary cortisol. In G. Fink (Ed.), Encyclopedia of stress (pp. 379–383). San Diego, CA: Academic Press.

    Google Scholar 

  • Klinger, R., Geiger, F., & Schiltenwolf, M. (2008). Can failed back surgery be prevented? Psychological risk factors for postoperative pain after back surgery. Der Orthopäde, 37, 1000–1006.

    Article  PubMed  Google Scholar 

  • Krämer, J. (2006). Bandscheibenbedingte Erkrankungen. Stuttgart, Germany: Thieme.

    Google Scholar 

  • Linton, S. L. (2000). A review of psychological risk factors in back and neck pain. Spine, 25, 1148–1156.

    Article  PubMed  Google Scholar 

  • Mc Lean, S. A., Williams, D. A., Harris, R. E., Kop, W. J., Groner, K. H., Ambrose, K., et al. (2005). Momentary relationship between cortisol secretion and symptoms in patients with fibromyalgia. Arthritis and Rheumatism, 52, 3660–3669.

    Article  Google Scholar 

  • Melzack, R. (2005). Evolution of the neuromatrix theory of pain. Pain Practice, 5, 85–94.

    Article  PubMed  Google Scholar 

  • Miller, G. E., Chen, E., & Zhou, S. (2007). If it goes up, must it come down? Chronic stress and the hypothalamic-pituitary-adrenocortical axis in humans. Psychological Bulletin, 133, 25–45.

    Article  PubMed  Google Scholar 

  • Moons, W. G., Eisenberger, N. I., & Taylor, S. E. (2010). Anger and fear responses to stress have different biological profiles. Brain, Behavior, and Immunity, 24, 215–219.

    Article  PubMed  Google Scholar 

  • Nakagawa, H., & Hosokawa, T. (1994). Study of the stress response to acute pain in the awake human. The Pain Clinic, 7, 317–324.

    Google Scholar 

  • Osthus, H., Cziske, R., & Jacobi, E. (2006). Cross-cultural adaptation of a German version of the Oswestry disability index and evaluation of its measurement properties. Spine, 31, E448–E453.

    Article  PubMed  Google Scholar 

  • Peters, M. L., Godaert, G. L. R., Ballieux, R. E., van Vliet, M., Willemsen, J. J., Sweep, F. C. G. J., et al. (1998). Cardiovascular and endocrine responses to experimental stress: Effects of mental effort and controllability. Psychoneuroendocrinology, 23, 1–17.

    Article  PubMed  Google Scholar 

  • Peters, M. L., Sommer, M., de Rijke, J. M., Kessels, F., Heineman, E., Patijn, J., et al. (2007). Somatic and psychologic predictors of long-term unfavorable outcome after surgical intervention. Annals of Surgery, 245, 487–494.

    Article  PubMed  Google Scholar 

  • Pfingsten, M. (2004). Fear avoidance beliefs in patients with back pain. Psychometric properties of the German version of the FABQ. Der Schmerz, 18, 17–27.

    Article  PubMed  Google Scholar 

  • Pfingsten, M., Leibing, E., Bansemer, C. F. D., Busch, O., & Hildebrand, J. (1997). Fear-avoidance-beliefs in patients with back pain. Der Schmerz, 11, 387–395.

    Article  PubMed  Google Scholar 

  • Pruessner, J. C., Baldwin, M. W., Dedovic, K., Renwick, R., Mahani, N. K., Lord, C., et al. (2005). Self-esteem, locus of control, hippocampal volume, and cortisol regulation in young and old adulthood. NeuroImage, 28, 815–826.

    Article  PubMed  Google Scholar 

  • Pruessner, M., Hellhammer, D. H., Pruessner, J. C., & Lupien, S. J. (2003a). Self-reported depressive symptoms and stress levels in healthy young men: associations with the cortisol response to awakening. Psychosomatic Medicine, 65, 92–99.

    Article  PubMed  Google Scholar 

  • Pruessner, J., Kirschbaum, C., Meinlschmid, G., & Hellhammer, D. (2003b). Two formulas for computation of the area under the curve represent measures of total hormone concentration versus time-dependent change. Psychoneuroendocrinology, 28, 916–931.

    Article  PubMed  Google Scholar 

  • Quartana, P. J., Buenaver, L. F., Edwards, R. R., Klick, B., Haythornthwaite, J. A., & Smith, M. T. (2010). Pain catastrophizing and salivary cortisol responses to laboratory pain testing in temporomandibular disorder and healthy participants. The Journal of Pain, 11, 186–194.

    Article  PubMed  Google Scholar 

  • Rothman, K. J. (1990). No adjustments are needed for multiple comparisons. Epidemiology, 1, 43–46.

    Article  PubMed  Google Scholar 

  • Schade, V., Semmer, N., Main, C. J., Hora, J., & Boos, N. (1999). The impact of clinical, morphological, psychosocial and work-related factors on the outcome of lumbar discectomy. Pain, 80, 239–249.

    Article  PubMed  Google Scholar 

  • Schmidt-Reinwald, A., Pruessner, J. C., Hellhammer, D. H., Federenko, I., Rohleder, N., Schürmeyer, T. H., et al. (1999). The cortisol response to awakening in relation to different challenge tests and a 12-h cortisol rhythm. Life Sciences, 64, 1653–1660.

    Article  PubMed  Google Scholar 

  • Schulz, P., Schlotz, W., & Becker, P. (2004). Trierer Inventar zum chronischen Stress. Manual. Göttingen, Germany: Hogrefe.

    Google Scholar 

  • Seligman, M. E. P. (1975). Helplessness. San Francisco, CA: W.H. Freeman.

    Google Scholar 

  • Stalder, T., Evans, P., Hucklebridge, F., & Clow, A. (2010). Associations between psychosocial state variables and the cortisol awakening response in a single case study. Psychoneuroendocrinology, 35, 209–214.

    Article  PubMed  Google Scholar 

  • Steptoe, A., Wardle, J., & Marmot, M. (2005). Positive affect and health-related neuroendocrine, cardiovascular, and inflammatory processes. Proceedings of the National academy of Sciences of the United States of America, 102, 6508–6512.

    Article  PubMed  Google Scholar 

  • Strittmatter, M., Bianchi, O., Ostertag, D., Grauer, M., Paulus, C., Fischer, C., et al. (2005). Altered function of the hypothalamic-pituitary-adrenal axis in patients with acute, chronic and episodic pain. Der Schmerz, 19, 109–116.

    Article  PubMed  Google Scholar 

  • Sudhaus, S., Fricke, B., Schneider, S., Stachon, A., Klein, H., van Düring, M., et al. (2007). The cortisol awakening response in patients with acute and chronic low back pain. Relations with psychological risk factors of pain chronicity. Der Schmerz, 21, 202–211.

    Article  PubMed  Google Scholar 

  • Sudhaus, S., Fricke, B., Stachon, A., Schneider, S., Klein, H., von Düring, M., et al. (2009). Salivary cortisol and psychological mechanisms in patients with acute versus chronic low back pain. Psychoneuroendocrinology, 34, 513–522.

    Article  PubMed  Google Scholar 

  • Ursin, H., & Eriksen, H. R. (2004). The cognitive activation theory of stress. Psychoneuroendocrinology, 29, 567–592.

    Article  PubMed  Google Scholar 

  • Ursin, H., & Eriksen, H. (2007). Cognitive activation theory of stress, sensitization, and common health complaints. Annals of the New York Academy of Sciences, 1113, 304–310.

    Article  PubMed  Google Scholar 

  • Valen, B., & Rolfsen, L. C. (1998). Quality assurance of back surgery. A follow-up of 350 patients treated for sciatica by means of survival analysis. Tidsskrift for den Norske Laegeforening, 118, 2136–2139.

    PubMed  Google Scholar 

  • van Stegeren, A. H., Wolf, O. T., & Kindt, M. (2008). Salivary alpha amylase and cortisol responses to different stress tasks: impact of sex. International Journal of Psychophysiology, 69, 33–40.

    Article  PubMed  Google Scholar 

  • Vedhara, K., Tuinstra, J., Miles, J. N. V., Sanderman, R., & Ranchor, A. V. (2006). Psychosocial factors associated with indices of cortisol production in women with breast cancer and controls. Psychoneuroendocrinology, 31, 299–311.

    Article  PubMed  Google Scholar 

  • Verbunt, J. A., Seelen, H. A., Vlaeyen, J. W., van der Heijden, G. J., Heuts, P. H., Pons, K., et al. (2003). Disuse and deconditioning in chronic low back pain: Concepts and hypothesis on contributing mechanisms. European Journal of Pain, 7, 9–21.

    Article  PubMed  Google Scholar 

  • Vlaeyen, J. W. S., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain, 85, 317–332.

    Article  PubMed  Google Scholar 

  • Waddell, G., Newton, M., Henderson, I., Somerville, D., & Main, C. J. (1993). A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain, 52, 157–168.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We thank Carolin Möllers for her assistance in data collection. Furthermore, we thank the anonymous reviewers for providing helpful comments on earlier versions of this manuscript.

Author information

Authors and Affiliations

  1. Department of Medical Psychology and Medical Sociology, Faculty of Medicine, Ruhr-University of Bochum, Universitätsstr. 150, 44780, Bochum, Germany

    Sigrid Sudhaus, Thomas Möllenberg, Heike Plaas & Monika Hasenbring

  2. Department of Rheumaorthopaedic Surgery, Orthopaedic University Clinic of Bochum, St. Elisabeth Hospital, Bochum, Germany

    Roland Willburger

  3. Neurosurgery Department of the Medical Faculty Mannheim, University of Heidelberg, Heidelberg, Germany

    Kirsten Schmieder

Authors
  1. Sigrid Sudhaus
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Thomas Möllenberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Heike Plaas
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Roland Willburger
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kirsten Schmieder
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Monika Hasenbring
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sigrid Sudhaus.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Sudhaus, S., Möllenberg, T., Plaas, H. et al. Cortisol Awakening Response and Pain-Related Fear-Avoidance Versus Endurance in Patients Six Months After Lumbar Disc Surgery. Appl Psychophysiol Biofeedback 37, 121–130 (2012). https://doi.org/10.1007/s10484-012-9186-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10484-012-9186-1

Keywords

Search

Navigation