Are fear-avoidance beliefs in low back pain patients a risk factor for low physical activity or vice versa? A cross-lagged panel analysis.

OBJECTIVE: The assumption that low back pain (LBP) patients suffer from "disuse" as a consequence of high fear-avoidance beliefs is currently under debate. A secondary analysis served to investigate whether fear-avoidance beliefs are associated cross-sectionally and longitudinally with the physical activity level (PAL) in LBP patients. METHODS: A total of 787 individuals (57% acute and 43% chronic LBP) were followed up over a period of one year with measurements of fear-avoidance beliefs and physical activity level. Fear-avoidance beliefs concerning physical activity were measured by the physical-activity subscale of the FABQ (Fear-Avoidance Beliefs Questionnaire), the physical activity level was assessed in weighted metabolic equivalents (MET) hours/week with a German self-report questionnaire. Data were investigated by structural equation modelling in a cross-lagged panel design for the whole sample and separately for acute and chronic LBP. RESULTS: The acute and chronic sub sample increased their total physical activity level significantly after one year. The structural equation modelling results did not support the disuse-aspect inherent in the fear-avoidance belief model. Cross-lagged path coefficients were low (.04 and .05 respectively) and, therefore, did not allow to predict final physical activity by initial fear-avoidance beliefs or vice versa. DISCUSSION: Consequently, due to missing links between fear-avoidance beliefs and physical activity in a longitudinal design, the assumptions of the fear-avoidance belief model have to be questioned. These findings are in line with other investigations published recently. Most probably, "fear-avoidance belief" represents a cognitive scheme that does not limit activity per se, but only is directed to the avoidance of specific movements.

Fear-avoidance beliefs, physical activity, and disability in elderly individuals with chronic low back pain and healthy controls.

OBJECTIVE: Research studies focussing on the fear-avoidance beliefs model (FABM) have expanded considerably during the last years, however, there has been very little research directed at the elderly. The objective of the present study was to investigate the validity of the FABM in older patients with chronic low back pain (CLBP). METHOD: In a cross-sectional study, a group of elderly patients with CLBP (N=103) was compared with an age-matched group of pain-free individuals (N=59) to test the constructs inherent in the FABM. Constructs include fear avoidance beliefs (FABs), disability, disuse, and physical activity. In addition, the relationship of these constructs was also investigated in the patient group. CLBP-patients had an average age of 71.41 years (SD=5.2) and pain-free individuals of 71.19 years (SD=4.73). Individuals participated in a photographed series of physical activities adapted to the age group (Photograph Series of Daily Activities-German version for the elderly) for the assessment of FAB, in the Hannover Disability Questionnaire, in the Freiburg Physical Activity Questionnaire, and in an ultrasound measurement to evaluate lumbar flexion. In addition, they completed an activity diary for 1 week. Before computation, the physical activity measurements were converted into metabolic units that characterize energy expenditure. RESULTS: In the patient group, FAB, pain intensity, and age predicted functional capacity, but not physical activity. Lumbar flexion was predicted by FAB and age. Patients were more fear-avoidant, reported more disability, and displayed less lumbar flexion than the pain-free individuals. No differences between the groups could be detected in regard to energy expenditure measured either by the questionnaire or by diary data. CONCLUSIONS: The findings are consistent with results reported in the literature for younger age groups and confirm the assumption that the FABM is also valid for the elderly.

TTM-based motivational counselling does not increase physical activity of low back pain patients in a primary care setting--A cluster-randomized controlled trial.

OBJECTIVE: To investigate the effectiveness of a TTM-based motivational counselling approach by trained practice nurses to promote physical activity of low back pain patients in a German primary care setting. METHODS: Data were collected in a cluster-randomized controlled trial with three study arms via questionnaires and patient interviews at baseline and after 6 and 12 months. We analysed total physical activity and self-efficacy by using random effect models to allow for clustering. RESULTS: A total of 1378 low back pain patients, many with acute symptoms, were included in the study. Nearly 40% of all patients reported sufficient physical activity at baseline. While there were significant improvements in patients' physical activity behaviour in all study arms, there was no evidence for an intervention effect. CONCLUSION: The outcome may be explained by insufficient performance of the practice nurses, implementation barriers caused by the German health care system and the heterogenous sample. PRACTICE IMPLICATIONS: Given the objective to incorporate practice nurses into patient education, there is a need for a better basic training of the nurses and for a change towards an organizational structure that facilitates patient-nurse communication. Counselling for low back pain patients has to consider more specificated aims for different subgroups.

Evaluating the accuracy of a simple heuristic to identify serious causes of low back pain.

BACKGROUND: Among patients presenting with low back pain (LBP), GPs have to identify those with serious, treatable conditions. However, excluding these conditions in every patient with LPB is time consuming and of low yield. We have suggested that identifying those patients where these serious conditions need to be considered can be made more efficient through asking patient if they feel their LBP is new or unfamiliar in some way. OBJECTIVE: To evaluate the diagnostic validity of a simple heuristic based on the patient's view of the familiarity of LBP. METHODS: Cross-sectional diagnostic study with delayed-type reference standard, nested within a three-arm randomized trial of quality improvement for LBP. A total of 1378 patients presenting, with LBP, to one of 126 participating GPs were included. They were asked whether their LBP was familiar or not (index test). At 1 year, patients were interviewed with regard to relevant conditions that in hindsight might explain their LBP. Reviewers deciding on disease status (reference standard) were blinded to the results of the index test. RESULTS: Totally 1190 patients answered the index test question and were available for interview at 1 year. Only four of these had a serious cause of their LBP. Two of these were identified by the familiarity heuristic, resulting in low sensitivity. CONCLUSION: The number of diseased patients was too small to obtain a reliable estimate of sensitivity. Low prevalence of serious disease in primary care poses difficulties for diagnostic research. In hindsight we would question whether an RCT-setting emphasizing non-specific LBP is suitable for this kind of research. At present, the familiarity heuristic cannot be recommended for patients presenting with LBP.