[Validation of the German version of the Fear-Avoidance Beliefs Questionnaire (FABQ-D) for shoulder disorders]. / Validierung der deutschen Version des Fear-Avoidance Beliefs Questionnaire (FABQ-D) für Patient*innen mit Schulterbeschwerden.

BACKGROUND: With a prevalence of up to 30%, shoulder disorders form the third largest group of musculoskeletal complaints worldwide. Their formation and development are influenced by psychosocial factors such as movement-related fear. One of the internationally most common measurements for quantifying fear of movement is the Fear-Avoidance Beliefs Questionnaire (FABQ). OBJECTIVES: To investigate the reliability (internal consistency) and validity (structural validity, construct validity, predictive validity) of the FABQ­D in a shoulder pain population. MATERIALS AND METHODS: Subjects with shoulder pain were included in a multicenter cross-sectional study. In addition to fear-avoidance beliefs, pain intensity, subjective impairment in daily life and kinesiophobia were recorded. To this end, the FABQ­D, numeric rating scale (NRS), Shoulder and Pain Disability Index (SPADI) and the Tampa Scale for Kinesiophobia (TSK-GV) were used. RESULTS: A total of 49 subjects (24 women and 25 men) with a mean age of 41.8 years (SD = 12.8) were included. The descriptive evaluation at item level showed good internal consistency of the FABQ­D (Cronbach's α = 0.88). The homogeneity factor differs significantly between the subscales (Loevinger's H = 0.66-0.9). The correlation analyses did not show any clear convergence of the FABQ­D with the TSK-GV (r = 0.3501; p = 0.0137). A divergence to the constructs of the NRS (r = 0.1818; p = 0.2112) and SPADI (r = 0.4415; p = 0.0015) were confirmed. The hypothesis testing resulted in 42.87% of the assumed hypotheses and therefore a low construct validity. The FABQ­D and the TSK-GV showed a significant influence on the duration of the complaints (R2 = 0.3652; p ≤ 0.0001). It was also shown that the greatest factors for a high FABQ­D value were functional impairment (SPADI) and duration of symptoms (R2 = 0.3066; p = 0.0002). The subgroup analysis showed a significantly higher FABQ­D value in older subjects (40-65 years; t = 3.8084/df = 47, p = 0.0002). CONCLUSION: The FABQ­D is a reliable measurement tool. The construct validity should be further investigated in future studies. This study reproduced results from previous studies in other populations. The FABQ­D appears to be an adequate measurement tool for quantifying fear of movement in patients with shoulder disorders.

Increased shoulder pain across an exercise session and subsequent shoulder exercise: a prospective cohort study.

BACKGROUND: Shoulder complaints are common and the recommended first-line treatment is exercise therapy. However, it remains unknown if increased shoulder pain after an exercise session is a barrier for subsequent exercise dose, particularly in people with high fear-avoidance beliefs. Such knowledge could indicate ways to optimise shoulder rehabilitation. The aim was to examine whether increased shoulder pain across an exercise session was associated with a lower subsequent exercise dose, and if high fear-avoidance beliefs exaggerated this association. METHODS: We conducted a prospective cohort study using data from a randomised controlled trial in Central Denmark Region 2017-2019. Participants were employees (n = 79) with shoulder complaints and high occupational shoulder exposures. The intervention was a home-based or partly supervised exercise programme lasting 2-3 months. Linear mixed models were used to examine the associations between change in shoulder pain and exercise dose (number of repetitions, progression level (1-3), resistance level (1-3), and time until next exercise session [days]). RESULTS: At baseline, the participants had a median pain intensity at rest of 2 on a numerical rating scale (0-10). For a 1-cm increase in pain on a visual analogue scale (0-10 cm) during an exercise session, the subsequent number of repetitions, progression level and resistance level were - 1.3 (95% confidence interval [CI] - 3.4 to 0.9), 0.0 (95% CI - 0.1 to 0.0) and - 0.0 (95% CI - 0.1 to 0.0), respectively. Likewise, the time until next exercise session was - 0.6 (95% CI - 2.4 to 1.3) days for a 1-cm increase. There were no interactions with fear-avoidance beliefs. CONCLUSION: Increased pain across an exercise session was not associated with subsequent exercise dose, regardless of fear-avoidance beliefs, among employees with shoulder complaints and high occupational shoulder exposures. TRIAL REGISTRATION: The trial was registered at Clinicaltrials.gov 19/05/2017 (ID: NCT03159910).

A cross-sectional hospital-based study of correlates of disability in patients with chronic low back pain in KwaZulu-Natal, South Africa.

BACKGROUND: Chronic low back pain (CLBP) is the leading cause of disability globally and is a major concern in public health. However, there is limited evidence on the prevalence and correlates of disability among adults in Sub-Saharan Africa. Thus, this study aimed at determining factors influencing disability among adult patients with CLBP in KwaZulu-Natal. METHODS: This analytical cross-sectional hospital-based study was conducted among adult CLBP patients in KwaZulu-Natal, South Africa. Data on disability, fear avoidance beliefs and illness behavior were gathered from 554 adult participants using self-administered questionnaires. Multiple linear regression analysis was conducted to determine factors associated with disability. Statistical significance was set at p < 0.05. RESULTS: Based on the multivariable linear regression, being a female (ß = 0.343, p < 0.001) and fear avoidance beliefs about work (ß = 0.221, p = 0.044) were significantly associated with greater disability, while, smoking 1 to 10 cigarettes per day (ß = -0.106, p = 0.011) and higher illness behaviour scores (ß = -0.165, p = 0.024) were significantly associated with less disability The model accounted for 20% of the total variance in Oswestry disability scores. CONCLUSION: This study has concluded that disability in CLBP is predicted by multiple of factors, with psychosocial factors (fear avoidance beliefs and heavy cigarette smoking) playing a significant role. Manual work was also identified as a significant predictor of CLBP disability. Therefore, guidelines should emphasize on early identification of these yellow flags in primary care.

Benefits of Adding Gluteal Dry Needling to a Four-Week Physical Exercise Program in a Chronic Low Back Pain Population. A Randomized Clinical Trial.

OBJECTIVE: To determine if adding dry needling to a four-week exercise program has an additional benefit compared with adding sham dry needling to the same exercise program in subjects with chronic low back pain. DESIGN: Randomized clinical trial. SETTING: Physiotherapy and Pain Clinic of Alcala University. SUBJECTS: Forty-six patients with chronic low back pain. METHODS: Subjects were randomized to two groups: the dry needling group (N = 23) or sham dry needling group (N = 23). Both groups received a four-week exercise program and before the exercise started a session of dry needling or sham dry needling. Pain (visual analog scale), disability (Roland-Morris Questionnaire), and fear avoidance beliefs (Fear Avoidance Beliefs Questionnaire) were assessed at baseline, after treatment, and at three-month follow-up. Pressure pain thresholds (algometer) were measured at baseline, after the dry needling or the sham dry needling, and after treatment. RESULTS: Both groups showed significant improvements for all variables. In the between-group comparison, the dry needling group improved significantly in pain at three-month follow-up and pressure pain thresholds at the end of treatment for all measures, and at three-month follow-up there was no improvement in gluteus medium. CONCLUSIONS: In chronic low back patients, adding dry needling to a four-week exercise program has an additional benefit in pain and sensitivity compared with adding sham dry needling to the same exercise program.

The Relationship Between Fear-avoidance Beliefs in Employees with Chronic Musculoskeletal Pain and Work Productivity: A Longitudinal Study.

This study aimed to identify risk factors for chronic musculoskeletal pain (CMSP) and sought to examine the effect of fear-avoidance beliefs (FABs) on work productivity in workers with CMSP. We performed a longitudinal study using self-administered questionnaires given to employees in three different industries between April 2016 and March 2017. The questionnaire concerned background characteristics, work-related factors and musculoskeletal pain, the Work Functioning Impairment Scale (WFun), and the Japanese version of the Tampa Scale for Kinesiophobia (TSK-J). We performed logistic regression analysis to evaluate factors affecting CMSP and a multi-way analysis of variance to analyze the relationship between FABs and CMSP and the effect of FABs on the ability to function at work. Age (odds ratio [OR] = 1.02, 95% confidence interval [CI]: 1.00-1.03), mean working hours (OR = 1.18, 95% CI: 1.04-1.33), and changes in working hours (OR = 1.18, 95% CI: 1.02-1.37) were significantly associated with CMSP. Regarding FABs, we found that the stronger the FAB, the greater the WFun score, and that an increase in FABs resulted in a significant increase in WFun scores. This study demonstrated that long or increased working hours may be risk factors for CMSP, and that stronger FABs in those with CMSP are associated with decreased ability to function at work. In addition, measures to reduce FABs in workers with CMSP may be effective.

Effectiveness of Simulated Horseback Riding for Patients With Chronic Low Back Pain: A Randomized Controlled Trial.

CONTEXT: A simulated horseback riding (SHR) exercise is effective for improvement of pain and functional disability, but its comparative effectiveness with the other is unknown. OBJECTIVE: The authors aimed to demonstrate the effect of a SHR exercise in people with chronic low back pain. DESIGN: A randomized controlled trial. SETTINGS: Community and university campus. PARTICIPANTS: A total of 48 participants with chronic low back pain were divided into 2 groups, and SHR exercises (n = 24) or stabilization (STB) exercises (n = 24) were performed. INTERVENTIONS: The exercises were performed for 30 minutes, 2 days per week for 8 weeks. MAIN OUTCOME MEASURES: Numeric rating scale, functional disabilities (Oswestry disability index and Roland-Morris disability), and fear-avoidance beliefs questionnaire (FABQ) scores were measured at baseline and at 4 weeks, 8 weeks, and 6 months. RESULTS: A 2-way repeated analysis of variance identified that between-group comparisons showed significant differences in the FABQ related to work scale (F = 21.422; P = .01). There were no significant differences in the numeric rating scale (F = 1.696; P = .21), Oswestry disability index (F = 1.848; P = .20), Roland-Morris disability (F = 0.069; P = .80), and FABQ related to physical scale (F = 1.579; P = .24). In within-group comparisons, both groups presented significant differences in numeric rating scale (both SHR and STB after 4 wk), Oswestry disability index (both SHR and STB after 6 mo), and Roland-Morris disability (SHR after 6 mo and STB after 8 wk) compared with baseline values. In FABQ-related physical (SHR after 4 wk) and work scales (SHR after 6 mo), there were only significant differences in the SHR compared with baseline values. CONCLUSIONS: SHR exercise for 8 weeks had a greater effect than STB exercise for reducing work-related FABQ. The SHR exercise performed in a seated position could substantially decrease pain-related fear disability in young adults with chronic low back pain.

Association between high fear-avoidance beliefs about physical activity and chronic disabling low back pain in nurses in Japan.

BACKGROUND: High prevalence of low back pain (LBP) in nurses has been reported globally. Ergonomic factors and work-related psychosocial factors have been focused on as risk factors. However, evidence on the role of fear-avoidance beliefs (FABs) concerning LBP in nurses is lacking. This study examined LBP prevalence and the association between FABs and chronic disabling LBP that interfered with work and lasted ≥ 3 months. METHODS: Female nurses (N = 3066; mean age = 35.8 ± 10.6 years) from 12 hospitals in Japan participated. A self-reported questionnaire was used to collect information on sociodemographics, LBP, work-related factors, and psychological distress. FABs about physical activity were assessed using a subscale from the FAB Questionnaire (score range = 0-24). The participants were asked to choose one of four statements regarding their LBP in the past 4 weeks: 1) I did not have LBP, 2) I had LBP without work difficulty, 3) I had LBP with work difficulty but without requiring absence from work, and 4) I had LBP requiring absence from work. If the participant had LBP in the past 4 weeks, it was also inquired if the LBP had lasted for ≥ 3 months. Chronic disabling LBP was defined as experiencing LBP with work difficulty in the past 4 weeks which had lasted for ≥ 3 months. In the nurses who had experienced any LBP in the past 4 weeks, we examined the association between FABs and experiencing chronic disabling LBP using multiple logistic regression models adjusting for pain intensity, age, body mass index, smoking status, psychological distress, hospital department, weekly work hours, night shift work, and the12 hospitals where the participants worked. RESULTS: Four-week and one-year LBP prevalence were 58.7 and 75.9%, respectively. High FABs (≥ 15) were associated with chronic disabling LBP (adjusted odds ratio = 1.76, 95% confidence interval [1.21-2.57], p = 0.003). CONCLUSIONS: LBP is common among nurses in Japan. FABs about physical activity might be a potential target for LBP management in nurses. TRIAL REGISTRATION: UMIN-CTR UMIN000018087. Registered: June 25, 2015.

"A body in transformation"-An empirical phenomenological study about fear-avoidance beliefs towards physical activity among persons experiencing moderate-to-severe rheumatic pain.

AIMS AND OBJECTIVES: To gain a better understanding of fear-avoidance beliefs towards physical activity and body awareness in people experiencing moderate-to-severe rheumatic pain. BACKGROUND: Rheumatoid arthritis and psoriatic arthritis are long-term conditions with pain as the prominent symptom. Health-promoting physical activity is recommended and can have an analgesic effect. High self-rated pain has previously been reported to be associated with increased fear-avoidance behaviour in relation to physical activity. Body awareness, which includes attentional focus and awareness of internal body sensations, could be valuable in the nursing care of long-term diseases. DESIGN: Empirical phenomenological. METHODS: An empirical phenomenological psychological method was applied. The interviews took place between autumn 2016-spring 2017 with 11 informants (eight women and three men, age range 44-71 years) who were diagnosed with rheumatoid arthritis (n = 7) or psoriatic arthritis (n = 4), with a disease duration ranging from 3-35 years. The mean visual analogue scale score in the study sample was 60 mm. RESULTS: Three typologies were identified: "My relatively fragile physical status", "I am an active creator" and "Part of something bigger than myself." CONCLUSIONS: The current findings indicated that pain anticipation and fear-avoidance beliefs towards physical activity sometimes affected the behaviour of individuals with long-term rheumatic pain syndromes. People experiencing moderate-to-severe rheumatic pain tended to focus on their fragile physical and emotional state. By adopting a more favourable attitude towards the self, the body could be restored to a state of calm and balance. RELEVANCE TO CLINICAL PRACTICE: The current findings are relevant for healthcare professionals engaged in health-promotion clinical practice.

Physiotherapists' Adoption of a Theory-Based Skills Training Program in Guiding People with Rheumatoid Arthritis to Health-Enhancing Physical Activity.

PURPOSE: To describe physiotherapists' (PTs') adoption of a theory-based skills training program preparing them to guide people with rheumatoid arthritis (RA) to health-enhancing physical activity (HEPA) within a 1-year intervention trial. METHOD: This was a longitudinal case study. Ten female PTs (age 25-59), delivering the HEPA intervention, participated. Data were collected on five occasions over a 19-month period: once before the training course, once after 4 course days, twice during the HEPA intervention and once after the HEPA intervention. Knowledge on about physical activity (score 0-6) and behavior change techniques (BCTs) (score 0-18), fear-avoidance beliefs (score 8-48) and self-efficacy to guide behavior change (score 9-54) were assessed with a questionnaire. Structured logbooks were used to register PTs' self-reported guiding behavior. Criteria for PTs' adherence to the protocol were pre-set. RESULTS: PTs' knowledge on about BCTs and their self-efficacy increased significantly (p < 0.05) from median 9 to 13 and from median 38 to 46.5, respectively. Knowledge on about physical activity was high and fear-avoidance beliefs were low before the education (median 6 and 13.5, respectively) and did not change over time. Two out of ten PTs fulfilled the pre-set criteria for adherence throughout the intervention. CONCLUSION: The results suggest that a theory-based skills training program improves PTs' knowledge on about behavior change techniques and their self-efficacy to guide people with RA to HEPA. PTs' adherence to the protocol was not complete but the clinical relevance of the adherence criteria need to be validated against observed PT behavior and patient outcomes.

Fear avoidance beliefs as a predictor for long-term sick leave, disability and pain in patients with chronic low back pain.

BACKGROUND: Subgrouping patients with chronic low back pain is recommended prior to selecting treatment strategy, and fear avoidance beliefs is a commonly addressed psychological factor used to help this subgrouping. The results of the predictive value of fear avoidance beliefs in patients with chronic low back pain in prognostic studies are, however, not in concordance. Therefore, the objective of this study was to examine the association between fear avoidance beliefs at baseline and unsuccessful outcome on sick leave, disability and pain at 12-month follow-up in patients with entirely chronic low back pain. METHODS: A secondary analysis of data from a randomised controlled trial. Patients with chronic low back pain (n = 559) completed questionnaires at baseline and after 12 months. Multiple logistic regression analyses were conducted to examine the association between fear avoidance beliefs and the outcomes sick leave, disability and pain. RESULTS: Higher fear avoidance beliefs about work at baseline were found to be significantly associated with still being on sick leave (OR 1.11; 95% CI 1.02-1.20) and having no reduction in pain (OR 1.04; 95% CI 1.01-1.08) after 12 months and may be associated with having no reduction in disability (OR 1.03; 95% CI 1.00-1.06) after 12 months (lower limit of 95% CI close to 1.00). Fear avoidance beliefs about physical activity were not found to be associated with the three outcomes. CONCLUSIONS: High fear avoidance beliefs about work are associated with continuous sick leave after 1 year in patients with chronic low back pain. This finding might assist clinicians in choosing targeted treatment strategies in subgroups of working patients with chronic low back pain.

The influence of pain-related beliefs on physical activity and health attitudes in patients with claudication: A pilot study.

We examined how pain beliefs are related to symptom severity, expectations of risk/benefits, and baseline physical activity among claudicants. Eligible patients at the Michael E DeBakey Veterans Affairs Medical Center were administered questionnaires that measured: fear-avoidance beliefs (Fear-Avoidance Beliefs Questionnaire [FABQ]), walking impairment, baseline physical activity, claudication type, and risk/benefit attitudes. Among 20 participants, the median age was 69 years (IQR: 66-75). In our efforts to understand how fear-avoidance beliefs influenced physical activity among people with claudication, we found that 12 out of 19 participants (63%) thought that the primary etiology of their pain was walking, while 18 (out of 20) (90%) people thought that walking would exacerbate their leg symptoms - suggesting that there was some confusion regarding the effects of walking on claudication. Those who expected that walking would benefit their symptoms more than surgery reported fewer fear-avoidance beliefs ( p=0.01), but those who believed that walking would make their leg pain worse expected greater benefit from surgery ( p=0.02). As symptom severity increased, fear-avoidance beliefs also increased ( p=0.001). The association between symptom severity and fear-avoidance beliefs indicates that as pain or impairment increases, the likelihood of avoiding behaviors that are thought to cause pain might also increase. Accounting for pain-related beliefs when recommending physical activity for claudication should be considered.

Resilience and Vulnerability Factors When Pain is Acute as Predictors of Disability: Findings From a Two-Year Longitudinal Study.

OBJECTIVE: To investigate the predictive power of resilience and vulnerability factors in relation to pain-related disability. DESIGN: A two-year prospective study investigated whether back pain-related disability was predicted by the following variables, measured when pain was acute: 1) pain-related disability, 2) pain intensity, 3) depression, 4) fear avoidance beliefs, 5) anxiety sensitivity, and 6) resilience. METHODS: Two hundred thirty-two patients treated in five primary care centers participated in this study. They were assessed at baseline during an acute back pain episode and at six, 12, 18, and 24 months. Ninety-nine patients completed all the assessment sessions. Linear mixed models were used to examine the trajectory of disability across the measurement occasions and its association with the predictors. RESULTS: Individuals who had higher scores of disability and pain intensity when pain was acute also had higher scores of disability six months later; moreover, the increase in disability was greater over time in comparison with individuals with lower scores in disability and pain intensity when pain was acute. Individuals who had reported greater levels of fear avoidance beliefs when pain was acute also reported greater scores of disability six months later; however, no differences were found in the rate of change in disability. No associations were found between initial disability or rate of change and resilience, anxiety sensitivity, or depression. CONCLUSIONS: Patients with acute back pain who show high levels of pain-related disability, pain intensity, and fear avoidance beliefs are at risk of developing back pain-related disability and should be the target of a preventive intervention.

The Key Role of Pain Catastrophizing in the Disability of Patients with Acute Back Pain.

PURPOSE: This study investigated the role of anxiety sensitivity, resilience, pain catastrophizing, depression, pain fear-avoidance beliefs, and pain intensity in patients with acute back pain-related disability. METHOD: Two hundred and thirty-two patients with acute back pain completed questionnaires on anxiety sensitivity, resilience, pain catastrophizing, fear-avoidance beliefs, depression, pain intensity, and disability. RESULTS: A structural equation modelling analysis revealed that anxiety sensitivity was associated with pain catastrophizing, and resilience was associated with lower levels of depression. Pain catastrophizing was positively associated with fear-avoidance beliefs and pain intensity. Depression was associated with fear-avoidance beliefs, but was not associated with pain intensity. Finally, catastrophizing, fear-avoidance beliefs, and pain intensity were positively and significantly associated with acute back pain-related disability. CONCLUSION: Although fear-avoidance beliefs and pain intensity were associated with disability, the results showed that pain catastrophizing was a central variable in the pain experience and had significant direct associations with disability when pain was acute. Anxiety sensitivity appeared to be an important antecedent of catastrophizing, whereas the influence of resilience on the acute back pain experience was limited to its relationship with depression.

The relationship between physical capacity and fear avoidance beliefs in patients with chronic low back pain.

[Purpose] The aim of this study was to investigate the relationship between physical capacity and fear avoidance beliefs in patients with chronic low back pain. [Subjects and Methods] This cross sectional study included 131 male university students with chronic low back pain. All the patients completed a fear avoidance beliefs questionnaire. Each participant performed a physical capacity test, which included hand grip force, leg strength, abdominal muscle endurance, flexibility, and cardiopulmonary endurance testing. [Results] Negative correlation was observed between physical capacity (leg strength, abdominal muscle endurance) and fear avoidance beliefs regarding work. Physical capacity (hand grip force, leg strength, cardiopulmonary endurance) showed a negative correlation with fear avoidance beliefs about physical activity. Abdominal muscle endurance and cardiopulmonary endurance were predictors of fear avoidance beliefs. [Conclusion] Physical capacity showed a negative correlation with fear avoidance beliefs in patients with chronic low back pain. The results of this study suggest that physical capacity is an important factor for predicting fear avoidance beliefs in patients with chronic low back pain.

Subjective health complaints, functional ability, fear avoidance beliefs, and days on sickness benefits after work rehabilitation - a mediation model.

BACKGROUND: Long-term sick leave and withdrawal from working life is a concern in western countries. In Norway, comprehensive inpatient work rehabilitation may be offered to sick listed individuals at risk of long-term absence from work. Knowledge about prognostic factors for work outcomes after long-term sick leave and work rehabilitation is still limited. The aim of this study was to test a mediation model for various hypothesized biopsychosocial predictors of continued sick leave after inpatient work rehabilitation. METHODS: One thousand one hundred fifty-five participants on long-term sick leave from eight different work rehabilitation clinics answered comprehensive questionnaires at arrival to the clinic, and were followed with official register data on sickness benefits for 3 years. Structural equation models were conducted, with days on sickness benefits after work rehabilitation as the outcome. RESULTS: Fear avoidance beliefs for work mediated the relation between both musculoskeletal complaints and education on days on sickness benefits after work rehabilitation. The relation between musculoskeletal complaints and fear avoidance beliefs for work was furthermore fully mediated by poor physical function. Previous sick leave had a strong independent effect on continued sick leave after work rehabilitation. Fear avoidance beliefs for work did not mediate the small effect of pseudoneurological complaints on continued sick leave. Poor coping/interaction ability was neither related to continued sick leave nor fear avoidance beliefs for work. CONCLUSIONS: The mediation model was partly supported by the data, and provides some possible new insight into how fear avoidance beliefs for work and functional ability may intervene with subjective health complaints and days on sickness benefits after work rehabilitation.

Do Teaching General Practitioners' Fear-Avoidance Beliefs Influence Their Management of Patients with Low Back Pain?

OBJECTIVES: To describe fear-avoidance beliefs about low back pain (LBP) in a sample of teaching general practitioners (TGPs) and to investigate the impact on following the guidelines for LBP. METHODS: A sample of 112 French TGPs were contacted to complete a self-administered questionnaire including socio-demographic and professional data, personal history of LBP, CME about LBP and usual practices, and their low back pain beliefs using the Fear-Avoidance Beliefs Questionnaire (FABQ) and the Back Belief Questionnaire (BBQ). RESULTS: Forty-seven responded, 48% treated more than 10 LBP patients per month, and 45% participated in an educational session on LBP during the previous 3 years. Seventy percent reported a previous episode of acute LBP, while 30% suffered from chronic LBP. The median scores for the FABQ-phys and work were 8 (4 to 10) and 17 (11 to 21), and 35 (31 to 38) for the BBQ. There were no correlations between age or years of practice and FABQ scores. TGPs suffering more than 1 acute LBP episode per month had a lower BBQ score (P < 0.05). Those prescribing more imaging exams in acute LBP had higher FABQ and lower BBQ scores, while those who recommended rest in both acute and chronic LBP had a higher FABQ-phys score. DISCUSSION: Teaching general practitioners' fear-avoidance beliefs about LBP are lower than previously reported by their GP colleagues but still negatively influence the way they follow guidelines for LBP patients. This may influence the way they teach the management of LBP.

Which Psychological and Psychosocial Constructs Are Important to Measure in Future Tendinopathy Clinical Trials? A Modified International Delphi Study With Expert Clinician/Researchers and People With Tendinopathy.

OBJECTIVE: To identify which psychological and psychosocial constructs to include in a core outcome set to guide future clinical trials in the tendinopathy field. DESIGN: Modified International Delphi study. METHODS: In 3 online Delphi rounds, we presented 35 psychological and psychosocial constructs to an international panel of 38 clinician/researchers and people with tendinopathy. Using a 9-point Likert scale (1 = not important to include, 9 = critical to include), consensus for construct inclusion required ≥70% of respondents rating "extremely critical to include" (score ≥7) and ≤15% rating "not important to include" (score ≤3). Consensus for exclusion required ≥70% of respondents rating "not important to include" (score ≤3) and ≤15% of rating "critical to include" (score ≥7). RESULTS: Thirty-six participants (95% of 38) completed round 1, 90% (n = 34) completed round 2, and 87% (n = 33) completed round 3. Four constructs were deemed important to include as part of a core outcome set: kinesiophobia (82%, median: 8, interquartile range [IQR]: 1.0), pain beliefs (76%, median: -7, IQR: 1.0), pain-related self-efficacy (71%, median: 7, IQR: 2.0), and fear-avoidance beliefs (73%, median: -7, IQR: 1.0). Six constructs were deemed not important to include: perceived injustice (82%), individual attitudes of family members (74%), social isolation and loneliness (73%), job satisfaction (73%), coping (70%), and educational attainment (70%). Clinician/researchers and people with tendinopathy reached consensus that kinesiophobia, pain beliefs, pain self-efficacy, and fear-avoidance beliefs were important psychological constructs to measure in tendinopathy clinical trials. J Orthop Sports Phys Ther 2024;54(1):1-12. Epub 20 September 2023. doi:10.2519/jospt.2023.11903.

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.

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.

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.