Outline of a fear-avoidance model of exaggerated pain perception—I
Abstract
The present paper describes a theoretical model for exaggerated pain perception which has been generated from a multidisciplinary team approach to the problem of chronic low-back pain. The model is an attempt to explain how and why some individuals develop a more substantial psychological overlay to their pain problem than do others.
Central to the model is the concept of ‘fear of pain’ which, it is suggested, leads to differing responses in different individuals. The two extreme responses are those of ‘confrontation’ and ‘avoidance’, although most individuals probably exhibit a mixture of the two. The former, it is argued, leads the individual to resume an increasing range of physical and social activities as the organic basis for the pain resolves and, as a consequence, ensures minimal psychological overlay. By contrast, an avoidance strategy is thought to produce a number of physical and psychological consequences which promote the development of the invalid status and the phenomenon of exaggerated pain perception.
The model suggests that the type of strategy adopted (i.e. confrontation or avoidance) is influenced by a number of psychosocial factors.
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Efficacy of cognitive functional therapy in patients with low back pain: A systematic review and meta-analysis
2024, International Journal of Nursing StudiesLow back pain is a major public health problem worldwide, and there exists evidence that cognitive functional therapy may help improve patients' health condition. However, the utilization of cognitive functional therapy for low back pain is limited, and its clinical efficacy remains unclear.
To determine the efficacy of cognitive functional therapy in the management of disability, pain intensity, and fear-avoidance beliefs in low back pain patients.
Systematic review and meta-analysis.
A comprehensive study search of Pubmed, Web of Science, Medline, CINAHL, Embase, PsycINFO, and the Cochrane Library databases was conducted from their inception to August 14th, 2023. Two researchers independently conducted the literature search and data extraction. All statistical analysis was performed using Stata Version 17.0.
A total of eight randomized controlled trials were included. In the short-term, cognitive functional therapy significantly improved disability (7 studies, SMD = − 1.05, 95 % CI = − 1.74 to − 0.35, I2 = 95.37 %, GRADE = very low), pain intensity (7 studies, SMD = − 1.02, 95 % CI = − 1.89 to − 0.15, I2 = 97.21 %, GRADE = very low), and fear-avoidance beliefs (4 studies, SMD = − 0.89, 95 % CI = − 1.30 to − 0.47, I2 = 82.49 %, GRADE = very low). In the medium-term, cognitive functional therapy also significantly improved disability (3 studies, SMD = − 0.48, 95 % CI = − 0.82 to − 0.14, I2 = 77.97 %, GRADE = very low), pain intensity (3 studies, SMD = − 0.34, 95 % CI = − 0.58 to − 0.10, I2 = 55.55 %, GRADE = very low), and fear-avoidance beliefs (2 studies, SMD = − 0.62, 95 % CI = − 1.19 to − 0.04, I2 = 88.24 %, GRADE = very low). In the long-term, cognitive functional therapy significantly improved disability (4 studies, SMD = − 0.54, 95 % CI = − 0.95 to − 0.13, I2 = 85.87 %, GRADE = very low) and fear-avoidance beliefs (3 studies, SMD = − 0.76, 95 % CI = − 1.17 to − 0.34, I2 = 80.34 %, GRADE = very low).
Cognitive functional therapy might be effective in reducing disability and fear-avoidance beliefs at any of short-, medium- and long-term follow-ups, and reducing pain at short- and medium-term follow-ups. No definitive conclusions can be drawn about the impact of cognitive functional therapy on low back pain patients due to the very low certainty evidence base. Additional rigorous randomized controlled trials are needed to further confirm these findings.
CRD42022287123 (PROSPERO).
Influence of Family-Learned Fear-of-Pain on Patients
2024, Pain Management NursingFear-of-pain is a common feeling of patients and their family who experience or witness severe or chronic pain. Fear-of-pain may disturb patient’s recovery, and also influence family support to assist patients' recovery.
This study is to measure the level of family support for each patient; evaluate the extent of the supporting families' fear-of-pain; and identify possible interventions in family support and family fear-of-pain.
This cross-sectional descriptive research involved 77 participants in the orthopedics department of a tertiary hospital by convenience sampling. The online questionnaire includes general information, and scales of fear-of-pain, pain anxiety, pain vigilance and awareness, pain catastrophizing, and family support. T-test, Pearson correlation analysis and Spearman correlation analysis were used to analyze data.
Most participants reported that they experienced a moderate-to-high level of fear-of-pain, pain anxiety, pain vigilance and awareness. A total of 15.6% of participants are at risk of pain catastrophizing. The family's pain vigilance and awareness, and fear-of-pain were often similar to those of the patient, and their levels of pain anxiety and catastrophizing were often higher than the patient's. Family support and families' fear-of-pain affect patients' feelings of pain and families' behavior in decision-making for patient recovery, necessitating the development of interventions for patients' families.
Family members can develop the fear-of-pain from witnessing painful experiences and may exhibit fear-avoidance behaviors in deciding on patients' rehabilitation plan. Family support, including the type of relationship with families, and length of time family spent with the patient, had an effect on patients' pain and fear-of-pain.
Pain-sensorimotor interactions: New perspectives and a new model
2024, Neurobiology of PainHow pain and sensorimotor behavior interact has been the subject of research and debate for many decades. This article reviews theories bearing on pain-sensorimotor interactions and considers their strengths and limitations in the light of findings from experimental and clinical studies of pain-sensorimotor interactions in the spinal and craniofacial sensorimotor systems. A strength of recent theories is that they have incorporated concepts and features missing from earlier theories to account for the role of the sensory-discriminative, motivational-affective, and cognitive-evaluative dimensions of pain in pain-sensorimotor interactions. Findings acquired since the formulation of these recent theories indicate that additional features need to be considered to provide a more comprehensive conceptualization of pain-sensorimotor interactions. These features include biopsychosocial influences that range from biological factors such as genetics and epigenetics to psychological factors and social factors encompassing environmental and cultural influences. Also needing consideration is a mechanistic framework that includes other biological factors reflecting nociceptive processes and glioplastic and neuroplastic changes in sensorimotor and related brain and spinal cord circuits in acute or chronic pain conditions. The literature reviewed and the limitations of previous theories bearing on pain-sensorimotor interactions have led us to provide new perspectives on these interactions, and this has prompted our development of a new concept, the Theory of Pain-Sensorimotor Interactions (TOPSMI) that we suggest gives a more comprehensive framework to consider the interactions and their complexity. This theory states that pain is associated with plastic changes in the central nervous system (CNS) that lead to an activation pattern of motor units that contributes to the individual’s adaptive sensorimotor behavior. This activation pattern takes account of the biological, psychological, and social influences on the musculoskeletal tissues involved in sensorimotor behavior and on the plastic changes and the experience of pain in that individual. The pattern is normally optimized in terms of biomechanical advantage and metabolic cost related to the features of the individual’s musculoskeletal tissues and aims to minimize pain and any associated sensorimotor changes, and thereby maintain homeostasis. However, adverse biopsychosocial factors and their interactions may result in plastic CNS changes leading to less optimal, even maladaptive, sensorimotor changes producing motor unit activation patterns associated with the development of further pain. This more comprehensive theory points towards customized treatment strategies, in line with the management approaches to pain proposed in the biopsychosocial model of pain.
The Pain Anxiety Symptom Scale: Initial Development and Evaluation of 4 and 8 Item Short Forms
2024, Journal of PainElevated levels of anxiety in relation to chronic pain have been consistently associated with greater distress and disability. Thus, accurate measurement of pain-related anxiety is an important requirement in modern pain services. The Pain Anxiety Symptom Scale (PASS) was introduced over 30 years ago, with a shortened 20-item version introduced 10 years later. Both versions of the PASS were derived using Principal Components Analysis, an established method of measure development with roots in classical test theory. Item Response Theory (IRT) is a complementary approach to measure development that can reduce the number of items needed and maximize item utility with minimal loss of statistical and clinical information. The present study used IRT to shorten the 20-item PASS (PASS-20) in a large sample of people with chronic pain (N = 2,669). Two shortened versions were evaluated, 1 composed of the single best-performing item from each of its 4 subscales (PASS-4) and the other with the 2 best-performing items from each subscale (PASS-8). Several supplementary analyses were performed, including comparative item convergence evaluations based on sample characteristics (ie, female or male sex; clinical or online sample), factor invariance testing, and criterion validity evaluation of the 4, 8, and 20-item versions of the PASS in hierarchical regression models predicting pain-related distress and interference. Overall, both shortened PASS versions performed adequately across these supplemental tests, although the PASS-4 had more consistent item convergence between samples, stronger evidence for factor invariance, and accounted for 83% of the variance accounted for by the PASS-20% and 92% of the variance accounted for by the PASS-8 in criterion variables. Consequently, the PASS-4 is recommended for use in situations where a briefer evaluation of pain-related anxiety is appropriate.
The Pain Anxiety Symptom Scale (PASS) is an established measure of pain-related fear. This study derived 4 and 8-item versions of the PASS using IRT. Both versions showed strong psychometric properties, stability of factor structure, and relation to important aspects of pain-related functioning.
Emotion-Focused Psychodynamic Interview for People with Chronic Musculoskeletal Pain and Childhood Adversity: A Randomized Controlled Trial
2024, Journal of PainChildhood adversity and emotional conflicts are associated with the presence and severity of chronic musculoskeletal pain (CMP), yet common treatments for CMP do not address such risk factors. We developed a single session, emotion-focused psychodynamic interview, based on Emotional Awareness and Expression Therapy and Intensive Short-term Psychodynamic Therapy, and we tested the interview’s effects on pain-related outcomes and potential psychological mediators in a randomized, controlled trial. Adults (N = 91; ages 21–70, M = 44.64; 87.9% women) reporting CMP and at least 3 adverse childhood experiences completed measures at baseline and 6-week follow-up. Participants were randomized to immediate interview or waitlist control conditions. The 90-minute interview was conducted via videoconference, and the interviewer elicited disclosure of adversities and conflicts, linked these with pain, and encouraged the experience and expression of adaptive emotions. Analyses indicated that conditions did not differ significantly on change in pain severity; however, compared to control, the interview led to a significantly greater reduction in pain interference (P = .016, ηp2 = .05) and a similar trend for anxiety (P = .058, ηp2 = .04). The interview also significantly changed several potential mediators: pain-related anxiety (P = .008, ηp2 = .06), pain controllability (P = .016, ηp2 = .06), and psychological (P < .001, ηp2 = .15) and brain attributions (P = .022, ηp2 = .05) for pain. Participants viewed the interview as very valuable. We conclude that addressing childhood adversities and conflicts in a psychodynamic interview is beneficial for people with CMP.
This study found that, compared to waitlist control, a 90-minute, remotely-administered, emotion-focused, psychodynamic interview improved pain interference, and anxiety among adults with chronic musculoskeletal pain and childhood adversity. Intensive emotional work can be done in a single session to the benefit of patients with chronic musculoskeletal pain.
Effect of Adding Diaphragmatic Breathing Exercises to Core Stabilization Exercises on Pain, Muscle Activity, Disability, and Sleep Quality in Patients With Chronic Low Back Pain: A Randomized Control Trial
2023, Journal of Chiropractic MedicineThe purpose of this study was to test the effect of adding diaphragmatic breathing exercises (DBEs) to core stabilization exercises (CSEs) for patients with chronic low back pain (CLPB).
Twenty-two patients with CLPB were randomly allocated to the experimental (DBE + CSE) or control group (CSE only). They were given 12 treatment sessions 3 times a week for 4 weeks. Patients were evaluated before and after the 12 sessions. Surface electromyography of transverse abdominis, Oswestry Disability Index, Fear Avoidance Belief Questionnaire, Pittsburgh Sleep Quality Index, Numeric Pain Rating Scale, and chest expansion were used as outcome measures for pain, muscle activity, disability, and sleep quality.
The outcome measure scores showed statistical significance of (P = .01) in time effect on muscle activity, sleep quality, disability score, pain score, fear-avoidance belief of patients and chest expansion; and group effect on Fear Avoidance Belief Questionnaire and physical activity parameter (P = .05). An interaction effect (time x group) on muscle activity for right transverse abdominus during tuck in (P = .01) and chest expansion (P = .01) was also found; however, no significant difference was found related to other parameters.
The combination of DBE and CSE interventions compared to CSE alone showed improvement in the measured parameters for patients with CLBP. Incorporating DBE with CSE also improved muscle activation and chest expansion.