Associations between the severity of disability level and fear of movement and pain beliefs in patients with chronic low back pain

1. Introduction

Low back pain (LBP) is one of the leading forms of chronic pain and is among the leading causes of pain and disability [1, 2]. The lifetime prevalence of LBP has been estimated to be 84%, and it has a great socioeconomic impact [3]. In addition, 25% of people with acute LBP experience recurrent episodes within a year; acute pain becomes chronic in 7 to 10% of these patients, based on reports in the literature [4, 5]. People with chronic low back pain may have difficulties in performing the activities of daily living, caring for their children, their social life and work-life, and have a poorer quality of life [6]. Chronic pain may lead to depression and avoidance of activity as a result of pain-related fear of movement and anxiety; all contribute to functional and social impairment and a reduced quality of life [7].

The fear-avoidance model forms a central theoretical framework to develop an understanding of the development and persistence of chronic musculoskeletal pain, particularly LBP. The term kinesiophobia derived from this model expresses the fear of movement experienced by the individual as a result of an increased pain perception and their response of avoidance or confrontation to cope with the pain [8]. Cross-sectional and proprioceptive studies reported that kinesiophobia was an important indicator of various stages of functional disability in low back pain and various pain conditions. In addition, high kinesiophobia may be a potential predictor for future disability and low back pain [9, 10, 11]. Moderate correlations have been reported among the Tampa Kinesiophobia Scale (TKS) scores (one of the two scales developed to measure fear of movement/reinjury) and the Roland Morris Disability Questionnaire [12, 13, 14, 15] and Oswestry Disability Index (ODI) scores [16].

Recent studies on chronic pain have demonstrated the important role of pain beliefs – one of the cognitive pain mechanisms – in the transition from acute to chronic pain and in therapeutic processes [17]. Ellis [18] stated that beliefs might include thoughts, attitudes, or images, but emotions have been reported as the primary determinant of pain beliefs. They also stated that beliefs were not constant truths but hypotheses and they were observable, testable, and changeable. Developing an understanding of pain beliefs in line with the above knowledge is of primary importance in pain management. This understanding may affect the beliefs of patients on the nature of their problems, make them familiar with specific treatment modalities, and may change their response to these treatments [17, 18]. In a literature review, Sertel-Berk and Bahadır [17] underlined pain control, pain belief, the type of behavior to overcome the pain, and the importance of subjective belief in the effectiveness of this behavior. Pain beliefs are generated by a person’s previous experiences with pain and healthcare as well as cultural and educational factors. Therefore, they reported that there was a need for studies on this issue in Turkey, and they also stated that the Pain Belief Questionnaire (PBQ) might be used in the assessment of pain belief. PBQ is a scale developed by Edwards et al. [19] that assesses psychological and organic belief allusions regarding the source and the outcome of pain in patients with chronic pain. The Pain Beliefs Questionnaire (PBQ) consists of two sub-dimensions. While the organic beliefs subscale (PBQ-O) questions the user about physical injury or physiological pain that threatens a healthy lifestyle, the psychological pain subscale (PBQ-P) evaluates internal factors and emotions that affect the pain experience that could potentially threaten health. In addition, PBQ-O evaluates perceived pain cause and management such as control and training/activity issues; therefore, it can be considered a biomedical measurement. The belief in organic pain causes patients to perceive pain as a harmful and uncontrollable condition associated with a devastating effect that may affect functional disability. Psychological pain beliefs are related to psychological state, anxiety, and depression, and patients with such beliefs should focus their attention on pain and relaxation [19, 20]. There are limited studies investigating pain beliefs in the literature. In a study investigating pain beliefs in patients with LBP, Walsh and Radcliffe [20] reported the significance of organic pain beliefs in pain-related disability and stated that reductions in organic pain beliefs were associated with improved disability outcomes. As far as we know, there are no studies investigating potential associations between pain beliefs and fear of movement in the literature. In the light of the above knowledge, we aimed to investigate the associations between fear of movement and pain beliefs by disability severity level in patients with chronic low back pain and the effects of these parameters on the quality of life and clinical manifestations.

2. Methods and materials

3. Results

Eighty-nine subjects (47 males, 42 females; mean age: 42.29 ± 16.05 years) and the means and standard deviations of the assessments are presented in Table 1. The VAS, ODI, TSK and PBQ scores were high in the patients, while all SF-36 subscale scores were low. When patients were grouped based on the disability scores [Group 1 (mild to moderate ODI; n : 24; 27%); Group 2 (severe ODI; n : 29; 32.5%); Group 3 (crippled ODI; n : 36; 40.5%)], a statistically significant increase with age was observed in Groups 2 and 3 ( 0.05, Table 2). No statistically significant differences were found in the TSK and PBQ scores ( $p>$ 0.05, Table 2) between groups.

A positive correlation was found between TSK scores, age ( r : 0.227, 0.05), PBQ organic ( r : 0.250, 0.05), SF-36 mental ( r : - 0.274, 0.05) scores. A positive correlation was found between the PBQ-O scores and age ( r : 0.291, 0.01), VAS scores/all SF-36 sub-dimensions scores (except SF-36 Role limitation – physical) ( 0.05–0.01). PBQ-P scores negatively correlated with the vitality ( r : - 0.246, 0.05) and social functioning ( r : - 0.357, 0.01) sub-dimensions of SF36 and positively correlated with the mental health sub-dimension ( r : - 0.317, 0.01). All correlations were weak (Table 3).

In this investigation of the associations between fear of movement and pain beliefs, as well as the impact of fear of movement and pain beliefs on the quality of life and clinical manifestations by disability levels in patients with chronic low back pain, TKS and Pain Beliefs subscale scores were similar when patients were grouped based on the severity of their disability (mild/moderate; severe; very severe). In other words, whether their disability was mild or very severe, patients similarly experienced high levels of fear of movement and had similar PBQ scores. In addition, TSK positively correlated with age and PBQ-O while it was negatively correlated with SF-36 mental sub-scores. Positive correlations were found between PBQ-O scores and TSK, VAS scores/all SF-36 sub-dimensions scores (except SF 36 Role limitation – physical). Remarkably, PBQ-O scores also correlated with VAS and TSK scores. PBQ-P scores negatively correlated with vitality sub-dimension/social function sub-dimension scores of SF-36 and positively correlated with the mental health sub-dimension. However, all correlations were weak.

Kinesiophobia, in other words “avoidance behavior due to fear,” is defined as “an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury” [9, 28]. In recent years, researchers have focused on kinesiophobia as a factor that causes the pain to persist and limits activities in patients with low back pain. Kinesiophobia has been reported as a factor limiting daily activities of living in patients with chronic low back pain, and kinesiophobia has been suggested to have negative impacts on the process of rehabilitation [29, 30]. In a study conducted by Vlaeyen et al. [31], scores higher than 37 were considered to indicate kinesiophobia. In our study, fear of movement scores were high, and this finding did not change with the severity of the disability.

In a study of 105 adult patients with low back pain, Guclu et al. [32] reported that fear-avoidance behaviors increased as the pain intensity increased. In our study, no significant correlations were observed between pain intensity and TSK scores. However, TSK scores were increased with age. In a study of 112 patients with LBP, Altug et al. [33] investigated potential associations between the presence of kinesiophobia and quality of life parameters. Investigators reported negative correlations between the presence of kinesiophobia and general health, physical functioning, social functioning, pain, and physical role limitation parameters. In a study of 94 patients with LBP, Ozmen et al. [34] could not find any associations between the presence of kinesiophobia and the quality of life, although the level of kinesiophobia was high, in line with our study. Differences between the results reported from different studies may be associated with small sample size, which is also a limitation of our study. Therefore, these associations should be investigated in studies with larger sample sizes.

Although pain has been thought to be a biological response to tissue damage, other dimensions of pain including genetic, emotional, and cultural characteristics and beliefs and personal factors have been defined and consequently, individual differences may be observed in pain experience and pain intensity, even though underlying physiological causes of pain may be similar [35, 36]. Currently, chronic pain is a universal problem with regard to severe impairment in psychosocial status and functionality. Pain control, particularly the control of chronic pain, has become an important necessity for improving health-related quality of life. It is important to understand the meaning attributed to pain, pain beliefs, and pain coping mechanisms and the use of this knowledge in the management of pain. Pain control, pain beliefs, and pain coping behaviors and the importance of subjective beliefs on the efficacy of these behaviors are emphasized in the literature review by Sertel-Berk and Bahadır [17]. The need for studies on pain beliefs in our country is also stated in this review.

There are limited studies on pain beliefs in the literature. In one of these studies, Rainville et al. [37] administered a treatment program focused on enhancing functionality that was planned for patients with LBP. Negative pain beliefs were common among patients who discontinued their treatment, and the researchers concluded that these beliefs might be reduced during the treatment. The findings from this study demonstrated that pain beliefs have a minimal role in compliance with treatment. However, this study is of particular importance since it demonstrated that these beliefs might change during treatments focused on enhancing functionality in patients with LBP. Walsh and Radcliffe [20] conducted a study investigating pain beliefs in 84 patients with LBP and reported that a reduction in organic pain beliefs as a result of cognitive therapy correlated with increases in functionality. They pointed out the significant relationships between pain beliefs and disability and quality of life scores and stated that positive pain beliefs might contribute to the success of treatment of these patients. In our study, negative correlations were demonstrated between PBQ-P beliefs and ODI scores, which reflected the level of functionality and vitality sub-dimension of SF-36. A correlation was found between PBQ-O and age, TSK, VAS, all SF-36 sub-dimension scores (except SF 36 Role limitation – physical). The positive correlation between PBQ-O scores and VAS scores was remarkable. In other words, patients more strongly believed that their pain was linked to organic causes. In addition, when the patients were grouped based on the severity of disability, pain beliefs were similar between patients, regardless the severity of disability. Based on these data, the participants were also concerned about organic factors in addition to psychological factors associated with pain; therefore, they considered pain as a symptom of the disease. However, unlike in the study by Walsh et al., we did not administer any treatment to our patients. We might observe different outcomes as a result of such treatments, and this was a limitation of our study. Another limitation of our study was that most of the data used in the assessment were self-reported, and participants were supposed to understand and respond accurately to the questions.

In conclusion, our study revealed high levels of kinesiophobia and similar pain beliefs independent of the disability level. Therefore, kinesiophobia and pain belief might have a negative impact on rehabilitation process in patients with chronic low back pain. On the other hand, we believe that rehabilitation procedures for chronic low back pain should include cognitive-behavioral therapy modalities that may reduce fear of movement and convert negative pain beliefs into positive ones, as the positive impact of the changes in pain beliefs was reported in previous studies in the literature.