Rev. Bras. Reumatol. vol.57 número4

ww w . r e u m a t o l o g i a . c o m . b r

REVISTA

BRASILEIRA

DE

REUMATOLOGIA

Original

article

Fear-avoidance

beliefs

increase

perception

of

pain

and

disability

in

Mexicans

with

chronic

low

back

pain

Tania

Inés

Nava-Bringas

_,

_Salvador

_Israel

_{Macías-Hernández,}

Jorge

Rodrigo

Vásquez-Ríos,

Roberto

Coronado-Zarco,

Antonio

Miranda-Duarte,

Eva

Cruz-Medina,

Aurelia

Arellano-Hernández

InstitutoNacionaldeRehabilitación,ServiciodeRehabilitacióndeColumna,MexicoCity,Mexico

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received26April2016 Accepted2September2016 Availableonline8December2016

Keywords:

Fear-avoidancebeliefs Chroniclowbackpain Disability

a

b

s

t

r

a

c

t

Background:Fear-avoidancebeliefsarerelatedtotheprognosisofchronicityinlowbackpain insubacutestages,howeverinchronicpain,isnocleartheinfluenceofthesefactors;ithas beensuggestedthatthestudypopulationcandeterminethemagnitudeofinfluenceon disabilityandpainofthosesufferingfrombackpain.Currently,informationdoesnotexist intheMexicanpopulation.

Objective:Toanalyzetherelationshipbetweenfear-avoidancebeliefswithpainanddisability inMexicanswithchroniclowbackpain;analyzepotentialsdifferencesbetweensubgroups accordingtothetimeofevolution.

Methods:Cross-sectionalstudyinMexicanswithchronicLBPagedbetween18and45.Data werecollectedongeneralsociodemographiccharacteristics,timeofevolution,bodymass index,pain,disabilityandfear-avoidancebeliefs.

Results:33menand47women,withanaverageageof34.19±7.65years.Higherscoresof fear-avoidancebeliefswereobtainedinwomen(47.2±20.99versus38.5±9.7;p=0.05)and singleparticipants(p=0.04).Apositivecorrelationwasfoundbetweendisability(r=0.603, p<0.001)andpain(r=0.234,p=0.03)withhighscoresoffear-avoidancebeliefs.Through generalizedlinearmodelsfordisability,totalscoreofthefearavoidancebeliefs question-naireshowedastandardizedbetacoefficientof0.603,p<0.001(R2_{of0.656);forpainshowed} astandardizedbetacoefficientof0.29,p=0.01(R2_of0.721).

Conclusion:Thepresentstudy suggeststhatthereisastrongrelationship betweenpain severity,FABQscores,andfunctionaldisabilityinMexicanswithchronicLBP.

©2016ElsevierEditoraLtda.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

∗ _{Correspondingauthor.}

E-mails:tanianava@gmail.com,tinava@inr.gob.mx(T.I.Nava-Bringas).

http://dx.doi.org/10.1016/j.rbre.2016.11.003

Crenc¸as

de

medo

e

evitac¸ão

aumentam

a

percepc¸ão

de

dor

e

incapacidade

em

mexicanos

com

lombalgia

crônica

Palavras-chave:

Crenc¸asdemedoeevitac¸ão Lombalgiacrônica

Incapacidade

r

e

s

u

m

o

Introduc¸ão: Ascrenc¸asdemedoeevitac¸ãoestãorelacionadascomoprognósticoda croni-cidadedalombalgianasfasessubagudas;contudo,nadorcrônica,nãoéclaraainfluência dessesfatores.Sugeriu-sequeumestudopopulacionalpodedeterminaramagnitudeda influênciadalombalgiasobreaincapacidadeeador.Atualmentenãoháinformac¸ãoaesse respeitonapopulac¸ãomexicana.

Objetivo: Analisararelac¸ãoentreascrenc¸asdemedoeevitac¸ãocomadore incapaci-dadeemmexicanoscomlombalgiacrônica;analisarpotenciaisdiferenc¸asentresubgrupos determinadospelotempodeevoluc¸ão.

Métodos: Estudotransversal em mexicanoscomlombalgia crônica entre18e 45 anos. Coletaram-se dadossobre característicassociodemográficas gerais,tempode evoluc¸ão, índicedemassacorporal,dor,incapacidadeecrenc¸asdemedoeevitac¸ão.

Resultados: Foramestudados33homense47mulherescommédiade34,19±7,65anos. Obtiveram-seescoresdecrenc¸asdemedoeevitac¸ãomaiselevadosemparticipantesdo sexofeminino(47,2±20,99versus38,5±9,7;p=0,05)esolteiros(p=0,04).Encontrou-seuma correlac¸ãopositivaentreaincapacidade(r=0,603,p<0,001)eador(r=0,234,p=0,03),com altaspontuac¸õesdecrenc¸asdemedoeevitac¸ão.Pormeiodemodeloslinearesgeneralizados paraincapacidade,apontuac¸ãototalnoquestionáriodecrenc¸asdemedoeevitac¸ãomostrou umcoeficientebetapadronizadode0,603,p<0,001(R2_{de0,656);paraador,mostrouum} coeficientebetapadronizadode0,29,p=0,01(R2_de0,721).

Conclusão: Opresenteestudosugerequeháumaforterelac¸ãoentreaintensidadedador, osescoresnoFABQeaincapacidadefuncionalemmexicanoscomlombalgiacrônica.

©2016ElsevierEditoraLtda.Este ´eumartigoOpenAccesssobumalicenc¸aCC BY-NC-ND(http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Promotinggradualphysicalreactivationandavoidingrestare

recommendedinthemanagement oflowback pain(LBP).1

However, these recommendations may not be carried out

byindividualsiftheypossesserroneousbeliefs,attitudesof avoidance,orfearofphysicalactivity.Thesepeoplemay gen-eratecatastrophicideationaboutpotentialdamage,whichin turnincreasesincapacityandpainandinterfereswithclinical courseandtreatmentadherence.2

Through the development and administration of the

“FearAvoidanceBeliefsQuestionnaire”(FABQ),datahasbeen obtainedthatsupportthe“Fear-AvoidanceModel”,previously

described by Vlaeyen and Linton, which explains how the

presenceoffearand/oravoidancebeliefstophysicalactivity, arerelatedtotheprognosisofchronicityinpeoplewithLBP insubacutestages(between6and12weeksofevolution);a findinginitiallydetectedinsalariedworkers.3,4

Inthe caseofpeople withchronicLBP (symptoms last-ing longer than 12 weeks)the findings are less consistent. It is for this reason that there is a current controversy surrounding the influence of these factors on the percep-tionofpainandlong-termassociateddisability.Additionally,

it is recommendable to analyze the impact of these

fac-torswith other variables suchas timeofevolution, taking into account peoples’status before and after 6months of symptomduration,andtypeofwork,sincepeoplewitha non-salariedoccupationhavebeenunderrepresentedinthisarea ofresearch.5

Ontheotherhand,theoriginsofstudypopulationcould

determine the magnitude of influence of fear-avoidance

beliefsondisabilityandqualityoflifeofthosesufferingfrom LBP;ithasbeenobservedthattheinfluenceofthesefactorsis lowerinpopulationsfromsoutheastEuropewhencompared topopulationsfromnorthernEurope.6,7

InMexico,in2012,astudywasreportedthataimedto com-parethepersonalitytypesof46MexicanswithchronicLBP

againstasymptomaticcontrolsusingtheTemperamentand

Character Inventory(TCI).Itwas foundthat scoreson this scale supported the “Fear-Avoidance Model”.However, this study includedparticipantsinsubacute stagesanddidnot analyzetheassociationbetweenfunctionalityandpain.Italso didnotanalyzetheinfluenceoftheresultsagainstpreviously describedfearandavoidancemodels.8

Currently,informationdoesnotexistregardingthese fac-tors in the Mexican population. This is why the research questions for this study were: Which is the relationship between fear-avoidance beliefs with pain and disability in Mexicanswithchroniclowbackpain?andArethere differ-encesbetweensubgroupswhentheyaredividedaccordingto thetimeofevolutionandoccupation?

Material

and

methods

eithersex,agedbetween18and45,andwithadiagnosisof mechanicalchronicLBP(definedaspainanddiscomfortfor morethan12weeksintheposteriorlumbarregionbetween the12thribsandinferiorglutealfolds,whichworsenswith physicalactivity,effort,andposturesandwhichimproveswith rest).Peoplewereexcludediftheyhadnon-mechanical lum-barpain,iftheywereilliterateorhadacognitivedeficitthat wouldhaveimpededtheirfillingoutofquestionnaires,orif theyhadanyassociatedcomorbiditiessuchas polyneuropa-thyorsystemicrheumaticillnesses.

TheInstitutionalEthicsCommitteeapprovedthisstudy.All participantsgavewritteninformedconsentbeforedata collec-tionbegan.Datawerecollectedongeneralsocio-demographic characteristics,suchasmaritalstatus,schooling,precedence, socioeconomiclevel,andoccupation.Thislastvariablewas stratifiedintopaidorunpaidwork,aswellasintoactivities thatareriskfactorsforchronicLBP.Timeofevolutionofthe LBPandbodymassindex(BMI)wererecordedforall partici-pants.

Forpain, the evaluationwasperformedusing a100mm longvisualanalogscale(VAS),considering“nopain”tobeat 0mm,and100mmtobe“unbearablepain.”

Fordisability:TheRolandMorrisQuestionnairewasused, whichisaself-administeredquestionnaireconsisting of24 items.Thetotalscorecanrangefrom0(nodisability)to24 (maximumdisability).Thisinstrumentisvalidatedforusein Spanishandhasbeenshowntobehighlyreliableandwith adequatereproducibility.9

Fear-avoidancebeliefs:TheFABQwasapplied,10_whichisan

instrument thatis alsovalidated inSpanish and hasbeen shownto begrammaticallycomprehensibleand reliable. It consistsof16itemsdividedintotwosub-scales:beliefsand fear at work (FABQ-W), and beliefs and fear to do physi-calactivity(FABQ-PA).Theitemsarescaledfrom0(“totally disagree”)to6(“completelyagree”).Greater scoresindicate higher levels of fear and beliefs about avoiding activities. AccordingtotheoriginalarticlebyWaddel,thefinalscoreis arrivedatbyadding bothsub-scales: sevenofthe11items relatedtowork(FABQ-W),witharangeof0–42points,andfour ofthefiveitemsrelatedtophysicalactivity(FABQ-PA).With anintervalof0–24,ahighscoreisconsideredtobeFABQ-PA above14.

Statisticalanalysis

Therequiredsamplesizewascalculatedconsideringa cor-relationcoefficient ofless than 0.50between the principal variables,inordertoachieve asignificancelevelof˛<0.05 andastatisticalpowerof80%.Thesamplesizerequiredwas atleast 29 people. Descriptive statistical analysis was run

to summarize the data. Chi-squared tests were performed

onqualitativevariables,andStudentttestsonquantitative variables;datawereproventobenormalwithaprior con-firmationthrougha Kolmogorov–Smirnovtest.Correlations wereexploredbetweenpainandfunctionalitywiththescore obtainedontheFABQ,aswellaswiththe restofthe vari-ablesthrough Pearson orSpearman tests,according tothe case.Multiplelinearregressionswereperformedtakingpain andfunctionalityintoaccount.Fortheconstructionof mul-tivariatemodels,variableswithp<0.15inunivariateanalysis

Table1–Resultsoftheadministrationofquestionnaires andclinicaldata.

n=80 Mean±SD

Evolutiontime(years) 4.43±5.03

Bodymassindex(BMI) 27.08±4.20

VAS(mm) 52.6±23.16

Functionality(RolandMorris) 9.56±5.20

FABtotalscore 42.09±20.55

FABPhysicalActivity 18.33±7.54

FABWork 23.43±16.16

FAB,FearAvoidanceBeliefsQuestionaire;SD,standarddeviation; VAS,visualanalogicscale.

wereincluded.Finalmodelswerethemostparsimonious.The significancelevelof˛was0.05.SPSSVersion17wasusedfor alldataanalysis.

Results

80 people(33 menand 47 women),withanaverageageof 34.19±7.65years,wereincludedinthestudy.Themajorityof thepeopleweredetermined,bythedepartmentofsocial ser-vicesofthehospital,tobefinanciallysolvent(56.3%),although 43.8%weredeterminedtobeindebtedorimpoverished.

Regarding marital status, 53.8%were single, 31.3% were married, 10%wereinadomesticpartnership,and5%were divorced.68.4%ofthepeoplehadanundergraduateor post-graduateuniversitydegree,35.1%middleorhighschooland 5%onlyhadanelementaryschooleducation.

Regardingoccupation,only21.3%ofthesampleperformed activities known toberiskfactors forLBP. 80%(60 people) receivedeconomicremunerationaspartoftheirwork.

Theresultsregardingevolutiontime,anthropometric mea-surementsand results ofthe appliedquestionnaires(pain, functionalityandFABQ)areshowninTable1.

Apositivecorrelationwasfoundbetweenfunctional dis-ability,measuredontheRoland–Morrisscale,withhighscores on theFABQ.These correlationswere foundwiththe total score(r=0.603,p<0.001),aswellaswiththePhysical Activ-ityandWorksubscales(FAB-PAr=0.314,p=0.008andFAB-W r=0.571,p<0.001).Functionalitywasalsofoundtobeinversely correlatedwithtimeofevolutionandschooling,higher per-centagesofincapacitywerefoundatless timeofevolution (r=−0.224;p=0.04),andatlowerlevelsofeducation(r=−0.28; p=0.01).RegardingpainmeasuredwiththeVASscale,it cor-relatedpositivelywiththetotalscoreontheFABQ(r=0.234, p=0.03),aswellaswithfunctionality(r=0.48,p<0.001).

Scores obtained on the FABQ showed significant

differ-ences betweenmenand women,with higherscoresfound

inmencompared towomen(47.2±20.99versus 38.5±19.7; p=0.05). Regarding marital status, higherscores were seen in single participants when compared to other categories (p=0.04).

Variousgeneralizedlinearmodelswerecalculated, consid-eringthedependentvariablestobethevaluesontheRoland MorrisQuestionnairefunctionalityandtheVAS scales.The modelwiththebestadjustedcoefficientofdeterminationwas sought,introducingthevariablesinablockforwardmethod.

FordisabilityevaluatedwiththeRolandMorris Question-naire,thebestmodelpresentedacorrectedR2of0.656.The totalscoreoftheFABQwasincludedinthefinalmodel,with astandardizedbetacoefficientof0.603(p<0.001).

InthecaseofpainmeasuredontheVAS,themodelwiththe bestfitwasfoundtohaveacorrectedR2_{of0.721;thismodel}

onlyincludedthevariableofFABQtotalscore,whichshowed astandardizedbetacoefficientof0.29(p=0.01).

Discussion

ChronicLBPisapublicglobalhealthproblem,anddespite var-iousdecadesofresearchonthe causes,thereisstillmuch unknownabout the factors that influence its development and chronicity,as wellas individualresponses toavailable treatments.11

Nearly all individuals will suffer an episode of LBP at somepointoftheirlives(80–90%),however,thereisnoclear

correlation between pain described by people and

anato-mopathologicalalterationsfound,and itisonlypossibleto reachanetiologicaldiagnosisin10–20%inLBPcases.12

Thereare manyfactorsassociatedwithchronicLBP,and thestructuralandbiomechanicalmodificationsdonot com-pletelyexplainall symptoms. Ampleliteraturereportsthat psychosocial factors are stronglyassociated withpain and disability.13

Withinthesefactors,fearandanxietyrelatedtoLBP gen-erate a series of physiological reactions (reactive muscle hypertonia),behavioralreactions(escapismandavoidanceof thepainful situation),and cognitive reactions(catastrophic ideation)in anindividual thatcan foment chronicity. This hasbeen widely described inliterature as“Fear-Avoidance Model.”3,14

Inthepresentstudy,thefearandavoidancebehaviorsin MexicanswithchronicLBPpredictedalargeproportionofthe degreeofdisabilityandpainwithoutregardtothe sociodemo-graphicoroccupationalcharacteristicsofourpopulation,and previouslyreportedasriskfactors.15,16

Leeuwetal.17_{mentionedthatwithintheFear-Avoidance}

Model, all related factors should be considered, like pain severityand priorhistory ofLBP,and together with hyper-vigilance/attentionto painand avoidance behaviors,it can determinetheevolutionofthedisorderandresponseto treat-ment.

Georgeand Stryker18 _{reportthe outcomesof313people}

withLBP,forwhomhighscoresontheFABQandseverityof painwerethetwoprincipalfactorsthatnegativelyaffected theirfunction.

Coincidingwith this line ofresearch, the present study suggests that there is a strong relationship between pain severity,FABQscores,and functionaldisabilityinMexicans withchronicLBP.

Asecondary aspect added tothis study was the analy-sisofbehaviorsinpopulationswithchronicLBPwho labor

innon-remuneratedoccupations.Thisisimportantbecause

the majority of studies focused on economically active

populationsshow highscoresontheFABQ associatedwith painandthetotalofworkdaysmissed.4,19

Since we could not quantify the workdays lost for

non-remunerated workers in our population, the principal variablestocomparethemwiththosewhoperformed remu-neratedactivitieswerepainanddisability.Nodifferenceswere observedbetweengroups,andbothwereassociatedwithfear attitudes andpain avoidanceand functionaldisability.Itis importanttoincludevariables tostudyunpaid workers(for example,housewives),whichallowedustomeasuretherole pain and disabilityplayed ininterruptingtheir dailywork. Theseinterruptionscanhavenegativeindirecteconomic con-sequences,astheycanaffectthefunctioningoftheirprimary networkandmostlikelywouldleadtoaredistributionoftasks toothermembersofthefamily.

Alimitationoftheresultspresentedhereisthatspecific evaluationswere notincluded todetectpsychiatric comor-bidities(anxietyanddepression)thatcouldmodifytheresults

in those who previously presented these diagnoses. The

importanceofthesecomorbiditiesisalreadyknowninthe per-sistenceofLBP,20_{however,weconsiderthatthesefirstreports}

arevaluableinthattheycontributetotheanalysisofhowthe fearandpainavoidancemodelinfluencesinMexicanswith LBP.

Therearestillunresolvedelements;thepresentstudywas

focused on Mexicansbetween the ages of18 and 45 with

unspecifiedchronicLBP,withoutexploringhowthefearand painavoidancemodelinfluencesinthepainprognosticsfor oldersubgroups.Ontheotherhand,prospectivecohort stud-iesshouldbeperformedtoanalyzehowthesefactorsinterfere intheresultsoftreatmentsandtreatmentadherence,andto generatevariablesthatwouldallowustomeasurepopulations ofunpaidworkersmoreeffectively.

As conclusion, the present study suggests that there is a strong relationship between pain severity, FABQ scores, andfunctionaldisabilityinMexicanswithchronicLBP.

Fear-avoidance beliefs show no differences between subgroups

dividedaccordingtothetimeofevolutionandoccupation.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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