Pain-related fear and movement : implications for physiotherapy and public health

Long-term musculoskeletal pain is a large public health problem with serious consequences both for the individual and society. Fear-avoidance beliefs and catastrophizing are powerful cognitions in the process of developing chronic pain problems. Fear-avoidance refers to the avoidance of movement or activities based on fear.

The overall aim of this thesis was to delineate the role of fear-avoidance beliefs in relation to the concept of movement. The specific aim of study I was to investigate possible differences on psychosocial variables between back pain sufferers with a recent history of being off work and those with similar pain but no sick absenteeism. The objective of study II was first to examine the occurrence of fear-avoidance beliefs and catastrophizing in the general population and secondly to assess whether fear-avoidance beliefs are related to current ratings of pain and activity level. Study III sought to prospectively investigate the effects of fear-avoidance beliefs on the genesis of future back pain. In study IV the aim was to examine the role of fear-avoidance beliefs and catastrophizing related to outcome measures at follow-up in a sample of patients with fractures.

The design of study I was cross-sectional and comprised 63 female hospital employees with low back pain. Study II was also cross-sectional and included 917 men and women from the general population with no or different degrees of spinal pain. Those in study 11 that were pain-free were later prospectively followed in study III regarding an inception of an episode of back pain (n=415). Study IV was of prospective design and comprised 70 patients with fractures of the wrist or the ankle.

Results showed that psychosocial factors, such as perceived health and attitudes about the relationship between pain and impairment, were discriminative between those being off work and those with no sick absenteeism. Higher levels of fear-avoidance beliefs increased the risk of having a lower level of activity. Higher levels of catastrophizing were related to ratings of pain with an increased risk by 1.8. Furthermore fear-avoidance beliefs increased the risk of the inception of a new episode of pain by 2 and catastrophizing increased the risk by 1.5. The risk of a lower physical function was increased by 1.5 regarding catastrophizing. Finally, higher levels of fear-avoidance beliefs increased the risk by three for having pain, and catastrophizing in relation to side difference regarding muscle strength was increased almost six times.

The studies underscore the importance of psychosocial factors such as fear-avoidance beliefs and catastrophizing regarding working ability and activity level. In line with earlier studies, the results suggest that these cognitions play an important part in musculoskeletal conditions, activity levels, and in the transition from acute to chronic pain. It is recommended that the knowledge is incorporated in screening procedures for early treatment and secondary prevention.

List of scientific papers

I. Linton SJ, Buer N (1995). Working despite pain: factors associated with work attendance versus dysfunction. Int J Behav Med. 2: 252-62.

II. Buer N, Linton SJ (2002). Fear-avoidance beliefs and catastrophizing: occurrence and risk factor in back pain and ADL in the general population. Pain. 99(3): 485-91.
https://pubmed.ncbi.nlm.nih.gov/12406524

III. Linton SJ, Buer N, Vlayen J, Hellsing AL (2000). Are fear-avoidance beliefs related to the inception of an episode of back pain? A prospective study. Psychol Health. 14: 1052-9.

IV. Buer N, Linton SJ, Samuelsson L, Harms-Ringdahl K (2003). The role of fearavoidance and catastrophizing in patients with fractures. [Submitted]