The impact of fear of attacks on pain-related disability in cluster headache: Insights from the fear avoidance model.

OBJECTIVE: This study utilized the theoretical framework of the "fear avoidance model" (FAM) and investigated the role of fear of attack in pain-related disability. To this end, a measurement specific to cluster headache (CH) was used to investigate whether fear of attacks, alongside attack frequency, is a significant predictor of pain-related disability in CH. BACKGROUND: Cluster headache substantially impacts daily functioning, yet empirical research exploring specific contributing factors is limited. METHODS: A cross-sectional online survey was undertaken in patients with CH, gathering sociodemographic, clinical data, and responses on the Cluster Headache Scale and the Depression, Anxiety and Stress Scale. RESULTS: Analysis of data from 640 patients (chronic CH: 287/640 [44.8%]; female: 264/640 [41.3%]; male: 373/640 [58.3%]; gender diverse: three of 640 [0.5%]; age range: 18-86 years; mean [standard deviation] Cluster Headache Scales subscale disability score: 36.9 [9.8]; out of 869 respondents) revealed that both attack frequency and fear of attacks significantly predicted pain-related disability (p < 0.001, percentage of variance explained: R2 = 0.24). More variance was explained by fear of attacks (R2 = 0.22) than by attack frequency (R2 = 0.02). This relationship remained significant even when controlling for depression and anxiety, which were also identified as independent predictors of pain-related disability (p < 0.001, R2 = 0.44). CONCLUSION: This study emphasizes the relevance of psychological factors in CH-related disability. Fear of attacks was found to be an independent predictor, while attack frequency was of minor relevance. Empirical investigation of the FAM in CH could improve the understanding of the mechanisms underlying disability and contribute to the development of CH-specific interventions.

Work-Related Fear-Avoidance Beliefs and Risk of Low-Back Pain: Prospective Cohort Study Among Healthcare Workers.

PURPOSE: Low-back pain (LBP) is a prevalent condition among healthcare workers, negatively affecting well-being and work ability. Research has identified fear-avoidance beliefs, i.e., the belief that physical activities worsen or prolong pain, as a key psychological factor in LBP. Given the physical demands of healthcare work, understanding the link between fear-avoidance and LBP is crucial for effective prevention and management strategies. This study investigated the prospective association between fear-avoidance beliefs and risk of increased LBP intensity and duration in hospital workers. METHODS: Fear-avoidance beliefs and LBP were assessed in 1933 healthcare workers from 389 departments at 19 hospitals at baseline and 1-year follow-up. Associations between baseline work-related fear-avoidance beliefs (FABW) and LBP intensity and duration at follow-up were analyzed using cumulative logistic regression, adjusting for various factors including age, sex, baseline LBP, education, seniority, patient transfers, psychosocial work environment, and lifestyle. RESULTS: Moderate and high FABW was associated with higher odds of increased pain intensity (OR: 1.37 [95% CI 1.09-1.73] and 1.85 [95% CI 1.18-2.88], respectively) and prolonged pain duration (OR: 1.37 [95% CI 1.05-1.78] and 2.27 [95% CI 1.50-3.44], respectively). A sensitivity analysis including only female nurses showed similar results, with the high FABW group having significantly higher odds of increased pain intensity (OR 2.95, 95% CI 1.84-4.72) and duration (OR 2.64, 95% CI 1.55-4.49). CONCLUSIONS: Fear-avoidance beliefs increase the risk of LBP intensity and duration among healthcare workers, emphasizing the need for interventions dealing with psychological aspects of LBP.

The association between conditioned pain modulation and psychological factors in people with chronic spinal pain: A systematic review.

Chronic spinal pain has negative effects on physical and mental well-being. Psychological factors can influence pain tolerance. However, whether these factors influence descending modulatory control mechanisms measured by conditioned pain modulation (CPM) in people with chronic spinal pain is unclear. This systematic review investigated the association between CPM response and psychological factors in people with chronic spinal pain. Published and unpublished literature databases were searched from inception to 23rd October 2023 included MEDLINE, EMBASE, CINAHL, and PubMed. Studies assessing the association between CPM response and psychological factors in people with chronic spinal pain were eligible. Data were pooled through meta-analysis. Methodological quality was assessed using the AXIS tool and the certainty of evidence measured through GRADE. From 2172 records, seven studies (n = 598) were eligible. Quality of included studies was moderate. There was very low certainty of evidence that depression (r = 0.01 [95% CI -0.10 to 0.12], I2 = 0%), and anxiety (r = -0.20 [95% CI -0.56 to 0.16], I2 = 84%), fear avoidance (r = -0.10 [95% CI -0.30 to 0.10], I2 = 70%) had no statistical associations with CPM responder status. Higher pain catastrophising was associated with CPM non-responder status (r = -0.19; 95% CI: -0.37 to -0.02; n = 545; I2: 76%) based on a very low certainty of evidence measured by GRADE. There is currently limited available evidence demonstrating an association between CPM response and psychological factors for people with chronic pain. Managing an individual's chronic pain symptoms irrespective of comorbid psychological distress, should continue until evidence offer insights that more targeted interventions are needed.

People With Acute Low Back Pain Have Concerns That May Not Be Addressed by Guideline-Recommended Advice: A Mixed-Methods Study.

OBJECTIVE: To investigate what concerns people with acute low back pain (LBP) and explore whether demographic and clinical factors were associated with having concerns about LBP. DESIGN: Mixed-methods study. METHODS: We included participants aged ≥18 years with acute LBP (LBP≤6 weeks). We collected demographic and clinical characteristics via an online survey and asked one open-ended question to elicit participants' concerns about their LBP. We investigated concerns about LBP using inductive content analysis. Using multivariable logistic regression, we explored associations between demographic and clinical characteristics and having concerns about LBP. RESULTS: We included 2025 participants, a majority of whom (n = 1200, 59.3%) reported having at least 1 concern about their LBP. There were 34 unique concerns, which mapped to 5 themes: causes of LBP (n = 393, 19.4%), future consequences of LBP (n = 390, 19.3%), psychosocial consequences of LBP (n = 287, 14.2%), physical consequences of LBP (n = 210, 10.4%), and health consequences of LBP (n = 84, 4.2%). Demographic and clinical characteristics were associated with having concerns about LBP: participants with university education, having previously received advice for LBP, with higher LBP intensity, interference, and higher anxiety symptoms were more likely to have concerns about their LBP. CONCLUSION: Most people with acute LBP had at least 1 concern about their LBP, more commonly centered around the causes of and the future consequences of LBP. J Orthop Sports Phys Ther 2024;54(9):1-9. Epub 7 August 2024. doi:10.2519/jospt.2024.12571.

Relationship between Fear-Avoidance Beliefs and Muscle Co-Contraction in People with Knee Osteoarthritis.

Excessive muscle co-contraction is one of the factors related to the progression of knee osteoarthritis (OA). A previous study demonstrated that pain, joint instability, lateral thrust, weight, and lower extremity alignment were listed as factors affecting excessive co-contraction in knee OA. However, this study aimed to assess the association between fear-avoidance beliefs and muscle co-contraction during gait and stair climbing in people with knee OA. Twenty-four participants with knee OA participated in this cross-sectional study. Co-contraction ratios (CCRs) were used to calculate muscle co-contraction during walking and stair climbing, using surface electromyography. Fear-avoidance beliefs were assessed by the Tampa Scale for Kinesiophobia-11 (TSK-11) for kinesiophobia and the Pain Catastrophizing Scale (PCS) for pain catastrophizing. Secondary parameters that may influence co-contraction, such as degree of pain, lateral thrust, weight, and lower extremity alignment, were measured. The relationships between the CCR during each movement, TSK-11, and PSC were evaluated using Spearman's rank correlation coefficient and partial correlation analysis, adjusted by weight and lower extremity alignment. Partial correlation analysis showed a significant correlation only between medial muscles CCR and TSK-11 during stair descent (r = 0.54, p < 0.05). Our study revealed that kinesiophobia could be associated with co-contraction during stair descent in people with knee OA.

Measurement Properties of Two Questionnaires Assessing Fear-Avoidance in Patients With Chronic Low Back Pain.

The Fear-Avoidance Components Scale (FACS) and the Fear of Daily Activities Questionnaire (FDAQ) assess fear-avoidance model components. However, the questionnaires are not available in Brazilian Portuguese. This study aimed to translate the original English FACS and FDAQ into Brazilian (Br) Portuguese and assess their measurement properties in patients with Chronic Low Back Pain (CLBP). One hundred thirty volunteers with CLBP participated in this study. Structural validity, internal consistency, test-retest reliability, and hypothesis testing for construct validity were analyzed. Results indicated a 2-factor solution for the FACS-Br, while the FDAQ-Br had a one-factor solution. Internal consistency showed acceptable Cronbach's alpha (alpha >.8). Suitable reliability was found for the FDAQ-Br (Intraclass Correlation Coefficient [ICC] = .98). For both FACS-Br factors, suitable reliability was found as well (ICC = .95 and .94). Hypothesis testing for construct validity confirmed more than 75% of the hypotheses proposed a priori for the FACS maladaptive pain/movement-related beliefs domain and the FDAQ-Br. In conclusion, the FACS-Br and FDAQ-Br demonstrated acceptable reliability, internal consistency, and structural validity measurement properties and their correlation (r < .50) suggests that the tools are not interchangeable measures.

Avoidance and Endurance Responses to Pain Before and with Advanced Chronification: Preliminary Results from a Questionnaire Survey in Adult Patients with Non-Cancer Pain Conditions.

Purpose: The Avoidance-Endurance Model postulates fear-avoidance responses and endurance responses as important psychological mechanisms in the development and maintenance of chronic pain. The present study aims to investigate potential differences in avoidance and endurance responses to pain before and with advanced chronification. Patients and Methods: Two samples of adults with non-cancer pain at two different stages of chronicity were compared: One with pain and risk factors for chronicity (n=26, part of the PAIN2020 project) and one with chronic pain (n=33 from a pain day care clinic). The German Pain Questionnaire, the Graded Chronic Pain Scale (GCPS) and medical reports were used to measure duration and severity of pain. Responses to pain were assessed with the Avoidance-Endurance Questionnaire (AEQ) and psychological strain with the Depression, Anxiety and Stress Scales (DASS). Results: Both groups were primarily affected by musculoskeletal pain. Although not yet chronified, the risk group reported comparable GCPS levels of pain intensity and disability. Depression and stress ratings were also similar, except for anxiety, which was significantly elevated in the chronic pain sample (p<.001). The AEQ scales did not differ between groups, neither on any of the fear-avoidance- nor endurance-related dimensions. A post-hoc regression analysis revealed a significant prediction of fear-avoidance by pain-related disability (p<.001). The regression model for endurance responses was not significant. Conclusion: Patients with risk factors of chronification experience substantial pain-related burden. Responses to pain in the realm of the Avoidance-Endurance model do not appear to vary as a function of chronification. While fear-avoidance and pain-related disability correlate positively, endurance could not be associated to any of our variables.

The persian version of the fear-avoidance beliefs questionnaire among iranian post-surgery patients: a translation and psychometrics.

INTRODUCTION: Fear-avoidance beliefs (FAB) play a crucial role in the treatment outcomes of post-surgery patients. These beliefs can lead to activity avoidance, increased pain, and decreased quality of life. Therefore, accurately measuring these beliefs in Iranian patients is of significant importance. The Fear-Avoidance Belief Questionnaire (FABQ) is a patient-reported questionnaire that evaluates individuals' FAB. Since the validity and reliability of the Persian version of FABQ (FABQ-P) have not been assessed based on the Iranian population and sociocultural contexts, the current study has been implemented to determine the reliability and validity of the FABQ-P among Iranian post-operative patients by translation and psychometric properties. METHODS: This methodological study conducted in 2023, a sample of 400 patients who had undergone surgery were selected using a convenience sampling method. The scale used in the study was translated and its psychometric properties were evaluated through network analysis and assessments of construct validity (including exploratory and confirmatory factor analysis), convergent validity, and discriminant validity. Additionally, the study assessed the internal consistency of the scale. RESULTS: The MLEFA results with Promax and Kaiser Normalization rotation yielded two factors explaining 57.91% of the variance, encompassing 13 items. Also, the model was approved by CFA. Convergent and discriminant validity have been confirmed through the following criteria: Average Variance Extracted (AVE) exceeding 0.5, Composite Reliability (CR) surpassing 0.7, and Heterotrait-Monotrait Ratio of Correlations (HTMT) equating to 0.597. As for reliability, Cronbach's alpha, composite reliability (CR), and MaxR for all constructs were greater than 0.7, demonstrating good internal consistency. CONCLUSION: As demonstrated by the results, the FABQ-P has a satisfactory level of reliability along with authentic validity according to the sociocultural contexts of Iranian post-operative patients.

Translation, cross-cultural adaptation, and measurement properties of the Arabic version of the fear avoidance components scale.

PURPOSE: This study aimed to translate, validate, and cross-culturally adapt the original FACS into the Arabic language. METHODS: The English version of the FACS was translated and culturally adapted into Arabic following international guidelines. The psychometric properties of the final version of the FACS-Arabic (FACS-A) were tested among 119 patients with different musculoskeletal (MSK) pain disorders. RESULTS: The Cronbach's α for the FACS-A was 0.86. The test-retest reliability, measured with intraclass correlation coefficient, was 0.80. The FACS-A showed positive significant correlations with other psychological patient-reported measures, including the pain catastrophizing scale (PCS) (r = 0.545); p ≤ 0.01), Brief Pain Inventory (BPI)-pain score (r = 0.546; p ≤ 0.01), BPI-pain interference score (r = 0.511; p ≤ 0.01), and Hospital Anxiety and Depression Scale (HADS) (r = 0.451, 0.336, respectively; p ≤ 0.01). Confirmatory factor analysis of the FACS-A confirmed the two-factor structure found in the original English version. CONCLUSION: This study determined the FACS-A to be a reliable and valid tool for the assessment of the fear-avoidance beliefs in Arabic-speaking individuals with MSK pain disorders.

The Arabic version of the fear avoidance component scale is a reliable and valid tool to assess pain fear-avoidance beliefs in individuals with musculoskeletal pain.This tool can be used to assess fear-avoidance beliefs in clinical practice for Arabic-speaking individuals.

Pain Neuroscience Education for Acute Pain.

In musculoskeletal and sports medicine, pain has traditionally been linked to tissue injury, often assuming a linear correlation between tissue damage and pain intensity. However, modern pain science has illuminated the complexity of the human pain experience, incorporating psychosocial elements, nervous system sensitization, immune responses, and structural changes in the brain as factors. This contemporary understanding of pain has proven highly beneficial for both clinicians treating individuals in pain and those experiencing pain. Pain neuroscience education (PNE) provides individuals in pain with an understanding of the underlying neurobiology and neurophysiology of their pain experience, which has been shown to result in decreased self-reported pain, reduced disability, the alleviation of fear and fear-avoidance behaviors, diminished pain catastrophizing, and improved movement. Currently, research on PNE predominantly focuses on interventions with individuals with persistent or chronic pain conditions. However, those who experience acute, sub-acute, and perioperative pain also have the potential for elevated levels of fear, fear-avoidance, and pain catastrophizing, indicating potential benefits from PNE. This invited commentary seeks to inform readers about the latest advancements in pain science and propose a conceptual model for delivering PNE in acute pain experiences. Level of Evidence: 5.

The fear-avoidance model as an embodied prediction of threat.

The fear-avoidance model is a well-established framework in the understanding of persistent pain. It proposes a dichotomous path: either the context is interpreted as safe; there is no fear reaction and, therefore, the individual engages in active (positive) coping; or the context is interpreted as threatening, leading to a self-reinforcing vicious circle of fear and (negative) avoidance. We propose an embodied interpretation of this phenomenon employing the joint framework of predictive coding and active inference. The key idea is that multisensory integration of exteroceptive, proprioceptive, and interoceptive sensory inputs can lead to dysfunctional experiences of threat in nonthreatening situations. Threat inference can promote fear responses, maladaptive strategies (i.e., avoidance) and self-provides evidence for threat in associated or future contexts, or both. Under this treatment, the prediction of nonrealized threat becomes self-evidencing and context-invariant, and hence self-perpetuating. Safety cues are unable to attenuate the interpretation of the negative context as the dominant inference of the context is threatful and gains more precision and becomes resistant over time. Our model provides an explanation for the emergence of a dysfunctional fear response in the clinical setting despite apparent safety based on modern concepts from theoretical (computational) neuroscience.

EFFects of Exposure and Cognitive behavioral Therapy for chronic BACK pain ("EFFECT-BACK"): study protocol for a randomized controlled trial.

INTRODUCTION: Chronic back pain is a widespread medical condition associated with high socioeconomic costs and increasing prevalence. Despite the advanced implementation of multidisciplinary approaches, providing a satisfactory treatment offer for those affected is often not possible. Exposure therapy (EXP) promises to be an effective and economical form of treatment and in a previous pilot study showed to be superior to cognitive behavioral therapy (CBT) in reducing perceived limitations of movement. The current study aims to further compare the efficacy of both treatment methods and identify those patient groups that particularly benefit from EXP. METHODS: The general objective of this randomized multicenter clinical trial (targeted N = 380) is to improve and expand the range of treatments available to patients with chronic back pain. As the primary objective of the study, two different psychological treatments (EXP and CBT) will be compared. The primary outcome measure is a clinically significant improvement in pain-related impairment, measured by the QPBDS, from baseline to 6-month follow-up. Secondary outcome measures are absolute changes and clinically significant improvements in variables coping, psychological flexibility, depressiveness, catastrophizing, exercise avoidance and fear of exercise, and intensity of pain. Participants are recruited in five psychological and medical centers in Germany and receive ten sessions of manualized therapy by trained licensed CBT therapists or clinical psychologists, who are currently in their post-gradual CBT training. Potential predictors of each treatment's efficacy will be explored with a focus on avoidance and coping behavior. CONCLUSION: This study will be the first RCT to compare CBT and EXP in chronic back pain in a large sample, including patients from different care structures due to psychological and medical recruitment centers. By identifying and exploring potential predictors of symptom improvement in each treatment group, this study will contribute to enable a more individualized assignment to treatment modalities and thus improves the care situation for chronic back pain and helps to create a customized treatment program for subgroups of pain patients. If our findings confirm EXP to be an efficacious and efficient treatment concept, it should gain more attention and be further disseminated. TRIAL REGISTRATION: ClinicalTrials.gov NCT05294081. Registered on 02 March 2022.

The role of concussion history and biological sex on baseline concussion clinical profile symptoms in adolescent rugby players.

BACKGROUND: Accurate concussion monitoring requires access to preinjury baseline data. This is particularly important in adolescent athletes who have a high risk of concussion and are prone to prolonged recovery. As Rugby Union is governed by similar laws for men and women, it is also an ideal population to rigorously examine the impact of biological sex on concussion symptoms. AIMS: To evaluate self-reported concussion symptoms at baseline in adolescent rugby union players, and examine if subtype-specific symptoms are affected by concussion history and biological sex. METHODS: Adolescent rugby union players aged 16-18 years were recruited during the 2022-2023 playing season. Participants completed a series of questionnaires covering post-concussion symptoms, concussion clinical profiles, anxiety, depression and fear avoidance behaviours. Independent variables of interest in analysis were biological sex and concussion history. RESULTS: 149 participants (75% male) were included. 42% (63/149) reported at least one previous concussion (average time since concussion: 18.7 months, range 1-72). Adolescents with a concussion history reported significantly higher scores than those with no history, across two clinical profiles (ocular and sleep), concussion symptom severity, and depression, all based on medium effect sizes (SMD 0.3-0.5). Females had significantly higher scores across cognitive/fatigue, ocular and sleep clinical profiles, concussion symptoms, anxiety and depression, each with large effect sizes (SMD > 0.5). CONCLUSIONS: Concussion history and sex are associated with higher baseline scores on specific concussion clinical profile, concussion symptom severity, and anxiety symptoms. These findings highlight the importance of considering baseline differences when interpreting post-injury clinical profile symptoms in adolescent rugby players. (Trial registration: ACTRN12622000931774).

Fear of movement and competence frustration mediate the relationship between pain catastrophising and physical function in people living with axSpA: an online cross-sectional survey.

The objective of this study is to examine the contribution of pain catastrophising to Axial Spondyloarthritis (axSpA) patient's physical function and to test the mediating role of fear of movement, and uniquely, the contribution of competence frustration to the fear-avoidance model. Participants (N = 98, 70% female, M age = 45.62, SD 12.16) completed an online survey (December 2020-May 2021) distributed in the United Kingdom via the National Axial Spondyloarthritis Society (n ≈ 3500; NASS, 2019). The PROCESS SPSS macro was used to test three mediation models using percentile bootstrap 95% confidence intervals (PBCI). A significant indirect effect on the relationship between pain and physical function via fear of movement (ß = 0.10, 95% PBCI = 0.030-0.183) was observed (Model 1). Model 2 showed the relationship between pain catastrophising and physical function to be significantly mediated by fear of movement (ß = 0.16, 95% PBCI = 0.005-0.322). Finally, Model 3 showed a significant indirect effect on the relationship between pain catastrophising and physical function via competence frustration (ß = 0.15, 95% PBCI = 0.014-0.309) but not through fear of movement (ß = 0.062, 95% PBCI = - 0.134 to 0.248). To our knowledge, this is the first study to examine and demonstrate the unique contribution of competence need frustration to the Fear-avoidance model in people that live with axSpA. Identifying modifiable factors that contribute to disease outcomes such as physical function can improve the care and quality of life for people living with a disease currently without a cure.

The mediating role of posttraumatic stress disorder symptoms in pain cognitions among Veterans with chronic pain.

Symptoms of posttraumatic stress disorder (PTSD) are highly prevalent among Veterans with chronic pain. Considerable research has examined the intersection of chronic pain and PTSD symptoms. However, it remains unclear whether changes in PTSD may potentially serve a mechanistic role in improving unhelpful pain cognitions for individuals with chronic pain. The present research contributes to the foundational knowledge by addressing this question. Baseline data from a randomized controlled trial targeting pain-related disability for Veterans (n = 103; mean age 43.66; SD = 10.17) with musculoskeletal pain and depression and/or PTSD symptoms were used. Cross-sectional mediation analyses showed that PTSD symptoms mediated the relationship between pain severity and pain catastrophizing, and between pain severity and pain acceptance. After controlling for depression, the mediation involving pain catastrophizing remained significant, while the mediation for pain acceptance did not. Although limitations exist, results point to several treatment recommendations, including ensuring that depressive affect, PTSD-specific symptoms, and attention to both body and mind are included in treatment. Results also provide preliminary evidence for examining these associations longitudinally to improve our understanding of this population and corresponding treatment recommendations.

The influence of psychological readiness of athletes when returning to sport after injury.

Background: Injuries are a common occurrence in sports participation; however, they have the potential to be accompanied by negative thoughts and feelings, which may play a part in the athletes' state of mind when they return to their sport. Assessing the degree to which this occurs provides an opportunity to evaluate and address athletes' state of mind before their return to play. Objectives: To determine if athletes are psychologically ready to return to play after an injury and if there are differences in fear avoidance behaviour between those who were and were not ready to return. Methods: Eighty-eight athletes participated in this descriptive survey. Athletes' confidence to return to play was measured by the Injury-Psychological Readiness to Return to Play (I-PRRS) questionnaire and their fear avoidance was measured by the Athlete Fear Avoidance Questionnaire (AFAQ). Results: Fifty injured athletes with a mean age of 23.3±4.0 years old responded to the I-PRRS and the AFAQ questionnaires. The average I-PRRS score was 46.5±9.1 AU. The evidence suggests that 60% of the athletes were not ready to return to sport (41.0±7.5 AU), whereas 40% were ready to return (54.8±3.1 AU). The difference in scores was not significant. The relationship between the AFAQ scores and the I-PRRS score for the 'ready' and 'not ready' groups was not significant (p=0.066). The mean AFAQ score (26.1±8.6 AU) for the 'not ready' group is marginally greater than the mean AFAQ score (21.6±7.5 AU) for the 'ready' group. There was a negative correlation between psychological readiness to return to sport and athletic fear avoidance (r =-0.508, p<0.001). Conclusion: There needs to be a greater utilisation of psychological assessment tools like the Injury-Psychological Readiness to Return to Play (I-PRRS) questionnaire, which can assist the athlete's support team, who can help identify athletes who are apprehensive about returning to sport after injury.

Health-Related Quality of Life and Psychological Outcomes in Participants with Symptomatic and Non-Symptomatic Knees after ACL Reconstruction.

Background: Individuals who sustain an ACL injury and undergo reconstruction (ACLR) are at risk for the development of osteoarthritis. Recent investigations have applied the Englund criteria to categorize people with a history of ACLR as someone with a symptomatic or asymptomatic knee. Purpose/Hypothesis: The purpose of this study was to examine differences in health-related quality of life (HRQL) and psychological outcomes in people with a history of ACLR who were categorized as symptomatic or non-symptomatic by application of the Englund criteria. The authors' hypothesized participants classified as symptomatic would have lower HRQL, increased fear-avoidance beliefs, and decreased resilience compared to participants classified as non-symptomatic. Study design: Cross-sectional, survey. Methods: Participants at least one-year after ACLR were recruited for the study and completed the Tegner Activity Scale, the Brief Resilience Scale (BRS), the modified Disablement in the Physically Active Scale (mDPA), and the Fear-Avoidance Belief Questionnaire (FABQ) at one time-point. Descriptive statistics were summarized using median [interquartile range] and differences between groups were examined using separate Mann-Whitney U tests. Results: Participants with symptomatic knees had a significantly higher BMI (24.8 [6.4]) than the non-symptomatic group (21.2 [4.3], p=0.013). Participants in the symptomatic group had worse HRQL on the physical subscale (12.5 [16.3] vs. 0.0 [2.5], p<0.001) and mental subscale (2.0 [1] vs. 0.0 [1], p=0.031), higher scores on the FABQ-Sport (14.5 [11] vs. 0.0 [6], p<0.001) and FABQ-Physical Activity (20 [24] vs. 1 [4], p<0.001) and less resilience (3.7[0.42] vs. 4.0 [0.83], p=0.028) compared to those participants in the non-symptomatic group. There were no differences in current physical activity (p=0.285) or change in physical activity (p=0.124) levels between the two groups. Conclusions: This series of differences may represent a cascade of events that can continue to negatively impact health outcomes across the lifespan for individuals with a history of ACLR. Future research should consider longitudinal investigations of these outcomes after injury and throughout the post-surgical and post-rehabilitation timeframe. Level of Evidence: Level 3b.

Effects of Embodiment in Virtual Reality for Treatment of Chronic Pain: Pilot Open-Label Study.

BACKGROUND: Chronic pain has long been a major health burden that has been addressed through numerous forms of pharmacological and nonpharmacological treatment. One of the tenets of modern medicine is to minimize risk while providing efficacy. Further, because of its noninvasive nature, virtual reality (VR) provides an attractive platform for potentially developing novel therapeutic modalities. OBJECTIVE: The purpose of this study was to determine the feasibility of a novel VR-based digital therapy for the treatment of chronic pain. METHODS: An open-label study assessed the feasibility of using virtual embodiment in VR to treat chronic pain. In total, 24 patients with chronic pain were recruited from local pain clinics and completed 8 sessions of a novel digital therapeutic that combines virtual embodiment with graded motor imagery to deliver functional rehabilitation exercises over the course of 4 weeks. Pain intensity as measured by a visual analog scale before and after each virtual embodiment training session was used as the primary outcome measure. Additionally, a battery of patient-reported pain questionnaires (Fear-Avoidance Beliefs Questionnaire, Oswestry Low Back Pain Disability Questionnaire, Pain Catastrophizing Scale, and Patient Health Questionnaire) were administered before and after 8 sessions of virtual embodiment training as exploratory outcome measures to assess if the measures are appropriate and warrant a larger randomized controlled trial. RESULTS: A 2-way ANOVA on session × pre- versus postvirtual embodiment training revealed that individual virtual embodiment training sessions significantly reduced the intensity of pain as measured by the visual analog scale (P<.001). Perceived disability due to lower back pain as measured by the Oswestry Low Back Pain Disability Questionnaire significantly improved (P=.003) over the 4-week course of virtual embodiment regimen. Improvement was also observed on the helplessness subscale of the Pain Catastrophizing Scale (P=.02). CONCLUSIONS: This study provides evidence that functional rehabilitation exercises delivered in VR are safe and may have positive effects on alleviating the symptoms of chronic pain. Additionally, the virtual embodiment intervention may improve perceived disability and helplessness of patients with chronic pain after 8 sessions. The results support the justification for a larger randomized controlled trial to assess the extent to which virtual embodiment training can exert an effect on symptoms associated with chronic pain. TRIAL REGISTRATION: ClinicalTrials.gov NCT04060875; https://clinicaltrials.gov/ct2/show/NCT04060875.

Factors associated with concerns about falling and activity restriction in older adults after hip fracture: a mixed-methods systematic review.

PURPOSE: To investigate factors contributing to concerns about falling and activity restriction in the community among older adults who had a hip fracture. METHODS: A mixed method systematic review with a convergent segregated approach. We searched Medline, Embase, PsycInfo, PEDRo, CINAHL and the Cochrane library. Results were synthesised narratively considering physical, psychological, environmental, care, and social factors and presented in tables. Critical appraisal was completed in duplicate. RESULTS: We included 19 studies (9 qualitative, 9 observational, 1 mixed methods) representing 1480 individuals and 23 factors related to concerns about falling and activity restriction. Physical factors included falls history, comorbidities, balance, strength, mobility and functionality. Psychological factors included anxiety and neuroticism scores, perceived confidence in/control over rehabilitation and abilities, and negative/positive affect about the orthopaedic trauma, pre-fracture abilities and future needs. Environmental factors included accessibility in the home, outdoors and with transport. Social and care factors related to the presence or absence of formal and informal networks, which reduced concerns and promoted activity by providing feedback, advice, encouragement, and practical support. CONCLUSION: These findings highlight that to improve concerns about falling and activity restriction after hip fracture, it is important to: improve physical and functional abilities; boost self-confidence; promote positive affect; involve relatives and carers; increase access to clinicians, and; enhance accessibility of the home, outdoors and transport. Most factors were reported on by a small number of studies of varying quality and require replication in future research.

The influence of psychological readiness of athletes when returning to sport after injury

Background: Injuries are a common occurrence in sports participation; however, they have the potential to be accompanied by negative thoughts and feelings, which may play a part in the athletes' state of mind when they return to their sport. Assessing the degree to which this occurs provides an opportunity to evaluate and address athletes' state of mind before their return to play. Objectives: To determine if athletes are psychologically ready to return to play after an injury and if there are differences in fear avoidance behaviour between those who were and were not ready to return. Methods: Eighty-eight athletes participated in this descriptive survey. Athletes' confidence to return to play was measured by the Injury-Psychological Readiness to Return to Play (I-PRRS) questionnaire and their fear avoidance was measured by the Athlete Fear Avoidance Questionnaire (AFAQ). Results: Fifty injured athletes with a mean age of 23.3±4.0 years old responded to the I-PRRS and the AFAQ questionnaires. The average I-PRRS score was 46.5±9.1 AU. The evidence suggests that 60% of the athletes were not ready to return to sport (41.0±7.5 AU), whereas 40% were ready to return (54.8±3.1 AU). The difference in scores was not significant. The relationship between the AFAQ scores and the I-PRRS score for the 'ready' and 'not ready' groups was not significant (p=0.066). The mean AFAQ score (26.1±8.6 AU) for the 'not ready' group is marginally greater than the mean AFAQ score (21.6±7.5 AU) for the 'ready' group. There was a negative correlation between psychological readiness to return to sport and athletic fear avoidance (r =-0.508, p<0.001). Conclusion: There needs to be a greater utilisation of psychological assessment tools like the Injury-Psychological Readiness to Return to Play (I-PRRS) questionnaire, which can assist the athlete's support team, who can help identify athletes who are apprehensive about returning to sport after injury.