fear avoidance beliefs increase perception of pain and disability in mexicans with chronic low back pain

Métodos: Estudotransversal em mexicanoscomlombalgia crônica entre18 e45 anos.. Coletaram-se dadossobre característicassociodemográficas gerais,tempode evoluc¸ão, índicedemassacorporal,dor

w w w r e u m a t o l o g i a c o m b r

REUMATOLOGIA

Original article

pain

Tania Inés Nava-Bringas∗, Salvador Israel Macías-Hernández,

Jorge Rodrigo Vásquez-Ríos, Roberto Coronado-Zarco, Antonio Miranda-Duarte,

Eva Cruz-Medina, Aurelia Arellano-Hernández

Instituto Nacional de Rehabilitación, Servicio de Rehabilitación de Columna, Cidade do México, Mexico

a r t i c l e i n f o

Article history:

Received26April2016

Accepted2September2016

Availableonlinexxx

Keywords:

Fear-avoidancebeliefs

Chroniclowbackpain

Disability

a b s t r a c t

Background:Fear-avoidancebeliefsarerelatedtotheprognosisofchronicityinlowbackpain

insubacutestages,howeverinchronicpain,isnocleartheinfluenceofthesefactors;ithas beensuggestedthatthestudypopulationcandeterminethemagnitudeofinfluenceon disabilityandpainofthosesufferingfrombackpain.Currently,informationdoesnotexist

intheMexicanpopulation

Objective:Toanalyzetherelationshipbetweenfear-avoidancebeliefswithpainanddisability

inMexicanswithchroniclowbackpain;analyzepotentialsdifferencesbetweensubgroups accordingtothetimeofevolution

Methods:Cross-sectionalstudyinMexicanswithchronicLBPagedbetween18and45.Data werecollectedongeneralsociodemographiccharacteristics,timeofevolution,bodymass index,pain,disabilityandfear-avoidancebeliefs

Results:33menand47women,withanaverageageof34.19±7.65years.Higherscoresof fear-avoidancebeliefswereobtainedinwomen(47.2±20.99versus38.5±9.7;p=0.05)and singleparticipants(p=0.04).Apositivecorrelationwasfoundbetweendisability(r=0.603,

p<0.001)andpain(r=0.234,p=0.03)withhighscoresoffear-avoidancebeliefs.Through generalizedlinearmodelsfordisability,totalscoreofthefearavoidancebeliefs question-naireshowedastandardizedbetacoefficientof0.603,p<0.001(R2of0.656);forpainshowed

astandardizedbetacoefficientof0.29,p=0.01(R2of0.721)

Conclusion: Thepresentstudy suggeststhatthereisastrongrelationship betweenpain severity,FABQscores,andfunctionaldisabilityinMexicanswithchronicLBP

©2016ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND

license(http://creativecommons.org/licenses/by-nc-nd/4.0/)

∗ Corresponding author.

E-mails:tanianava@gmail.com,tinava@inr.gob.mx(T.I.Nava-Bringas)

http://dx.doi.org/10.1016/j.rbre.2016.11.003

2255-5021/©2016ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/)

Crenc¸as de medo e evitac¸ão aumentam a percepc¸ão de dor e incapacidade em mexicanos com lombalgia crônica

Palavras-chave:

Crenc¸asdemedoeevitac¸ão

Lombalgiacrônica

Incapacidade

r e s u m o

Introduc¸ão: Ascrenc¸asdemedoeevitac¸ãoestãorelacionadascomoprognósticoda croni-cidadedalombalgianasfasessubagudas;contudo,nadorcrônica,nãoéclaraainfluência dessesfatores.Sugeriu-sequeumestudopopulacionalpodedeterminaramagnitudeda influênciadalombalgiasobreaincapacidadeeador.Atualmentenãoháinformac¸ãoaesse respeitonapopulac¸ãomexicana

Objetivo: Analisararelac¸ãoentreascrenc¸asdemedoeevitac¸ãocomadore incapaci-dadeemmexicanoscomlombalgiacrônica;analisarpotenciaisdiferenc¸asentresubgrupos determinadospelotempodeevoluc¸ão

Métodos: Estudotransversal em mexicanoscomlombalgia crônica entre18 e45 anos Coletaram-se dadossobre característicassociodemográficas gerais,tempode evoluc¸ão, índicedemassacorporal,dor,incapacidadeecrenc¸asdemedoeevitac¸ão

Resultados: Foramestudados33homense47mulherescommédiade34,19±7,65anos Obtiveram-seescoresdecrenc¸asdemedoeevitac¸ãomaiselevadosemparticipantesdo sexofeminino(47,2±20,99versus38,5±9,7;p=0,05)esolteiros(p=0,04).Encontrou-seuma correlac¸ãopositivaentreaincapacidade(r=0,603,p<0,001)eador(r=0,234,p=0,03),com altaspontuac¸õesdecrenc¸asdemedoeevitac¸ão.Pormeiodemodeloslinearesgeneralizados paraincapacidade,apontuac¸ãototalnoquestionáriodecrenc¸asdemedoeevitac¸ãomostrou

umcoeficientebetapadronizadode0,603,p<0,001(R2de0,656);paraador,mostrouum coeficientebetapadronizadode0,29,p=0,01(R2de0,721)

Conclusão: Opresenteestudosugerequeháumaforterelac¸ãoentreaintensidadedador,

osescoresnoFABQeaincapacidadefuncionalemmexicanoscomlombalgiacrônica

©2016ElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCC

BY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.0/)

Introduction

Promotinggradualphysicalreactivationandavoidingrestare

recommendedinthemanagement oflowback pain(LBP).1

However, these recommendations may not be carried out

byindividualsiftheypossesserroneousbeliefs,attitudesof

avoidance,orfearofphysicalactivity.Thesepeoplemay

gen-eratecatastrophicideationaboutpotentialdamage,whichin

turnincreasesincapacityandpainandinterfereswithclinical

courseandtreatmentadherence.2

Through the development and administration of the

“FearAvoidanceBeliefsQuestionnaire”(FABQ),datahasbeen

obtainedthatsupportthe“Fear-AvoidanceModel”,previously

described by Vlaeyen and Linton, which explains how the

presenceoffearand/oravoidancebeliefstophysicalactivity,

arerelatedtotheprognosisofchronicityinpeoplewithLBP

insubacutestages(between6and12weeksofevolution);a

findinginitiallydetectedinsalariedworkers.3,4

Inthe caseofpeople withchronic LBP(symptoms

last-ing longer than 12 weeks)the findings are less consistent

It is for this reason that there is a current controversy

surrounding the influence of these factors on the

percep-tionofpainandlong-termassociateddisability.Additionally,

it is recommendable to analyze the impact of these

fac-torswith other variables suchas timeofevolution, taking

into account peoples’status before and after 6months of

symptomduration,andtypeofwork,sincepeoplewitha

non-salariedoccupationhavebeenunderrepresentedinthisarea

ofresearch.5

Ontheotherhand,theoriginsofstudypopulationcould determine the magnitude of influence of fear-avoidance beliefsondisabilityandqualityoflifeofthosesufferingfrom LBP;ithasbeenobservedthattheinfluenceofthesefactorsis lowerinpopulationsfromsoutheastEuropewhencompared

topopulationsfromnorthernEurope.6,7

InMexico,in2012,astudywasreportedthataimedto com-parethepersonalitytypesof46MexicanswithchronicLBP againstasymptomaticcontrolsusingtheTemperamentand Character Inventory(TCI) Itwasfoundthat scoreson this scale supported the “Fear-Avoidance Model”.However, this study includedparticipants insubacute stagesanddidnot analyzetheassociationbetweenfunctionalityandpain.Italso didnotanalyzetheinfluenceoftheresultsagainstpreviously describedfearandavoidancemodels.8

Currently,informationdoesnotexistregardingthese fac-tors in the Mexican population This is why the research questions for this study were: Which is the relationship between fear-avoidance beliefs withpain and disability in Mexicanswithchroniclowbackpain?andArethere differ-encesbetweensubgroupswhentheyaredividedaccordingto thetimeofevolutionandoccupation?

Across-sectionalstudywasperformedintheoutpatient ser-vices of the Spine Rehabilitation Services of the National Institute of Rehabilitation in Mexico City Theparticipants were recruitedbased onthefollowingcriteria: Mexicansof

eithersex,agedbetween18and45,andwithadiagnosisof

mechanicalchronicLBP(definedaspainanddiscomfortfor

morethan12weeksintheposteriorlumbarregionbetween

the12thribsandinferiorglutealfolds,whichworsenswith

physicalactivity,effort,andposturesandwhichimproveswith

rest).Peoplewereexcludediftheyhadnon-mechanical

lum-barpain,iftheywereilliterateorhadacognitivedeficitthat

wouldhaveimpededtheirfillingoutofquestionnaires,orif

theyhadanyassociatedcomorbiditiessuchas

polyneuropa-thyorsystemicrheumaticillnesses

TheInstitutionalEthicsCommitteeapprovedthisstudy.All

participantsgavewritteninformedconsentbeforedata

collec-tionbegan.Datawerecollectedongeneralsocio-demographic

characteristics,suchasmaritalstatus,schooling,precedence,

socioeconomiclevel,andoccupation.Thislastvariablewas

stratifiedintopaidorunpaidwork,aswellasintoactivities

thatareriskfactorsforchronicLBP.Timeofevolutionofthe

LBPandbodymassindex(BMI)wererecordedforall

partici-pants

Forpain, the evaluationwasperformedusinga 100mm

longvisualanalogscale(VAS),considering“nopain”tobeat

0mm,and100mmtobe“unbearablepain.”

For disability:TheRolandMorrisQuestionnairewasused,

whichisaself-administeredquestionnaireconsistingof24

items.Thetotalscorecanrangefrom0(nodisability)to24

(maximumdisability).Thisinstrumentisvalidatedforusein

Spanishandhasbeenshowntobehighlyreliableandwith

adequatereproducibility.9

Fear-avoidance beliefs:TheFABQwasapplied,10whichisan

instrument thatis alsovalidated inSpanish and hasbeen

showntobe grammaticallycomprehensibleand reliable It

consistsof16itemsdividedintotwosub-scales:beliefsand

fear at work (FABQ-W), and beliefs and fear to do

physi-calactivity (FABQ-PA).Theitemsarescaledfrom0(“totally

disagree”)to6(“completelyagree”).Greater scoresindicate

higher levels of fear and beliefs about avoiding activities

AccordingtotheoriginalarticlebyWaddel,thefinalscoreis

arrivedatbyadding bothsub-scales: sevenofthe11items

relatedtowork(FABQ-W),witharangeof0–42points,andfour

ofthefiveitemsrelatedtophysicalactivity(FABQ-PA).With

anintervalof0–24,ahighscoreisconsideredtobeFABQ-PA

above14

Statistical analysis

Therequiredsamplesizewascalculatedconsideringa

cor-relationcoefficient ofless than 0.50 between the principal

variables,inordertoachieve asignificancelevelof˛<0.05

andastatisticalpowerof80%.Thesamplesizerequiredwas

atleast 29 people Descriptive statistical analysis was run

tosummarize the data Chi-squared tests were performed

onqualitativevariables,andStudentttestsonquantitative

variables;datawereproventobenormalwithaprior

con-firmationthrougha Kolmogorov–Smirnovtest.Correlations

wereexploredbetweenpainandfunctionalitywiththescore

obtainedon theFABQ,aswellaswiththe restofthe

vari-ablesthrough Pearsonor Spearman tests,according tothe

case.Multiplelinearregressionswereperformedtakingpain

andfunctionalityintoaccount.Fortheconstructionof

mul-tivariatemodels,variableswithp<0.15inunivariateanalysis

Table 1 – Results of the administration of questionnaires and clinical data.

wereincluded.Finalmodelswerethemostparsimonious.The significancelevelof˛was0.05.SPSSVersion17wasusedfor alldataanalysis

Results

80 people(33 menand 47 women),withanaverageageof 34.19±7.65years,wereincludedinthestudy.Themajorityof thepeopleweredetermined,bythedepartmentofsocial ser-vicesofthehospital,tobefinanciallysolvent(56.3%),although 43.8%weredeterminedtobeindebtedorimpoverished Regarding marital status,53.8% were single, 31.3%were married, 10%wereinadomesticpartnership, and5%were divorced.68.4%ofthepeoplehadanundergraduateor post-graduateuniversitydegree,35.1%middleorhighschooland 5%onlyhadanelementaryschooleducation

Regardingoccupation,only21.3%ofthesampleperformed activities known toberiskfactors forLBP 80%(60 people) receivedeconomicremunerationaspartoftheirwork Theresultsregardingevolutiontime,anthropometric mea-surementsand results oftheapplied questionnaires(pain, functionalityandFABQ)areshowninTable1

Apositivecorrelationwasfoundbetweenfunctional dis-ability,measuredontheRoland–Morrisscale,withhighscores

on theFABQ.These correlationswere foundwiththe total score(r=0.603,p<0.001),aswellaswiththePhysical Activ-ityandWorksubscales(FAB-PAr=0.314,p=0.008andFAB-W

r=0.571,p<0.001).Functionalitywasalsofoundtobeinversely correlatedwithtimeofevolutionandschooling,higher per-centagesofincapacitywerefoundatlesstimeofevolution

(r=−0.224;p=0.04),andatlowerlevelsofeducation(r=−0.28;

p=0.01).RegardingpainmeasuredwiththeVASscale,it cor-relatedpositivelywiththetotalscoreontheFABQ(r=0.234,

p=0.03),aswellaswithfunctionality(r=0.48,p<0.001) Scores obtained on the FABQ showed significant differ-ences betweenmenand women,with higherscoresfound

inmencomparedto women(47.2±20.99versus 38.5±19.7;

p=0.05) Regarding marital status,higher scores were seen

in single participants when compared to other categories

(p=0.04)

Differenceswere notfound betweengroupsin termsof FABQscoreswhenparticipantsweredividedintotwogroups basedontimeofevolution,beforeandafter6months(p=0.23) Differenceswerealsonotfoundwhenpeopleweredividedby remuneratedworkorunpaidlabor(p=0.42)

Variousgeneralizedlinearmodelswerecalculated, consid-eringthedependentvariablestobethevaluesontheRoland MorrisQuestionnaire functionalityand theVAS scales.The

modelwiththebestadjustedcoefficientofdeterminationwas

sought,introducingthevariablesinablockforwardmethod

FordisabilityevaluatedwiththeRolandMorris

Question-naire,thebestmodelpresentedacorrectedR2of0.656.The

totalscoreoftheFABQwasincludedinthefinalmodel,with

astandardizedbetacoefficientof0.603(p<0.001)

InthecaseofpainmeasuredontheVAS,themodelwiththe

bestfitwasfoundtohaveacorrectedR2of0.721;thismodel

onlyincludedthevariableofFABQtotalscore,whichshowed

astandardizedbetacoefficientof0.29(p=0.01)

Discussion

ChronicLBPisapublicglobalhealthproblem,anddespite

var-iousdecadesofresearchonthe causes,thereisstillmuch

unknownabout the factors that influence its development

and chronicity,as wellas individualresponses toavailable

treatments.11

Nearly all individuals will suffer an episode of LBP at

somepointoftheirlives(80–90%),however,thereisnoclear

correlation between pain described by people and

anato-mopathologicalalterationsfound, anditisonlypossibleto

reachanetiologicaldiagnosisin10–20%inLBPcases.12

TherearemanyfactorsassociatedwithchronicLBP,and

thestructuralandbiomechanicalmodificationsdonot

com-pletelyexplainall symptoms Ampleliteraturereportsthat

psychosocial factors are stronglyassociated withpain and

disability.13

Withinthesefactors,fearandanxietyrelatedtoLBP

gen-erate a series of physiological reactions (reactive muscle

hypertonia),behavioralreactions(escapismandavoidanceof

thepainful situation),and cognitive reactions(catastrophic

ideation) inan individual thatcan foment chronicity This

hasbeen widely described inliterature as“Fear-Avoidance

Model.”3,14

Inthepresentstudy,thefearandavoidancebehaviorsin

MexicanswithchronicLBPpredictedalargeproportionofthe

degreeofdisabilityandpainwithoutregardtothe

sociodemo-graphicoroccupationalcharacteristicsofourpopulation,and

previouslyreportedasriskfactors.15,16

Leeuwetal.17mentionedthatwithintheFear-Avoidance

Model, all related factors should be considered, like pain

severityand priorhistory ofLBP,and together with

hyper-vigilance/attention topainand avoidance behaviors, itcan

determinetheevolutionofthedisorderandresponseto

treat-ment

GeorgeandStryker18 reportthe outcomesof313people

withLBP,forwhomhighscoresontheFABQandseverityof

painwerethetwoprincipalfactorsthatnegativelyaffected

theirfunction

Coincidingwith this line ofresearch, the present study

suggests that there is a strong relationship between pain

severity,FABQscores,and functionaldisabilityinMexicans

withchronicLBP

Asecondary aspect added tothis study wasthe

analy-sisofbehaviorsinpopulationswithchronicLBPwho labor

innon-remuneratedoccupations.Thisisimportantbecause

the majority of studies focused on economically active

populationsshow highscoresontheFABQ associatedwith painandthetotalofworkdaysmissed.4,19

Since we could not quantify the workdays lost for non-remunerated workers in our population, the principal variablestocomparethemwiththosewhoperformed remu-neratedactivitieswerepainanddisability.Nodifferenceswere observedbetweengroups,andbothwereassociatedwithfear attitudes andpain avoidanceand functionaldisability.Itis importanttoincludevariablestostudy unpaidworkers(for example,housewives),whichallowedustomeasuretherole pain and disability playedininterruptingtheir dailywork Theseinterruptionscanhavenegativeindirecteconomic con-sequences,astheycanaffectthefunctioningoftheirprimary networkandmostlikelywouldleadtoaredistributionoftasks

toothermembersofthefamily

Alimitationoftheresultspresentedhereisthatspecific evaluationswere notincluded todetectpsychiatric comor-bidities(anxietyanddepression)thatcouldmodifytheresults

in those who previously presented these diagnoses The importanceofthesecomorbiditiesisalreadyknowninthe per-sistenceofLBP,20however,weconsiderthatthesefirstreports arevaluableinthattheycontributetotheanalysisofhowthe fearandpainavoidancemodelinfluencesinMexicanswith LBP

Therearestillunresolvedelements;thepresentstudywas focused on Mexicans betweenthe ages of18 and 45 with unspecifiedchronicLBP,withoutexploringhowthefearand painavoidancemodelinfluencesinthepainprognosticsfor oldersubgroups.Ontheotherhand,prospectivecohort stud-iesshouldbeperformedtoanalyzehowthesefactorsinterfere

intheresultsoftreatmentsandtreatmentadherence,andto generatevariablesthatwouldallowustomeasurepopulations

ofunpaidworkersmoreeffectively

As conclusion, the present study suggests that there is

a strong relationship between pain severity, FABQ scores, andfunctionaldisabilityinMexicanswithchronicLBP Fear-avoidance beliefs show no differences between subgroups dividedaccordingtothetimeofevolutionandoccupation

Theauthorsdeclarenoconflictsofinterest

r e f e r e n c e s

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