title: [Psychological mechanisms in the transition from acute to chronic pain: over- or underrated?]. Fear-avoidance Beliefs, Physical Activity, and Disability in Elderly Individuals With Chronic Low Back Pain and Healthy Controls
abstract: INTRODUCTION During the last 20 years a great number of studies have emphasized the potential role of psychological factors as relevant predictors for the first onset of back pain as well as for the development of chronic pain . The formulation of a biopsychosocial perspective of the etiology and chronicity of back pain was a natural consequence . Actual questions concern the relative impact of psychological risk factors in the process of chronicity of back pain compared to biomedical , social and occupational factors . METHODS Whereas several review articles regarding the role of psychological risk factors are available up to now , a recently published review conducted by Steven Linton was the first systematic analysis of well controlled prospect i ve studies published since 1967 . Using a grading system similar to that recommended for guidelines the author defined a level A evidence when at least two good- quality prospect i ve studies supported the prospect i ve power of a variable . Level B evidence had support from one prospect i ve study . Level C represented inconclusive data and level D indicated that no studies met the criteria . Based on a literature search of more than 900 studies , 37 good- quality prospect i ve studies were analysed in detail . RESULTS The results indicated level A evidence for the following interrelations : ( 1 ) Psychosocial variables , especially chronic distress in daily life , depression and work dissatisfaction were clearly associated with the onset of back and neck pain ( 2 ) . Psychological variables , especially chronic stress in daily life , work dissatisfaction , depression and pain-related cognitions and coping behaviour were clearly linked to the transition from acute to chronic pain and disability ( 3 ) . Psychological variables generally had more prospect i ve power than biomedical , social or objective occupational variables . Among the pain-related cognitions , catastrophizing and fear-avoidance-beliefs yielded the most empirical support . Among coping behaviour passive coping stretegies such as avoiding behaviour was most important . At least level B evidence has been shown for the counterpart of an extreme suppressive coping behaviour . Patients who tended to suppress or ignore pain in order to finish all activities they started , who were unable to integrate phases of passive relaxation into the daily routine displayed a high risk of chronicity of pain 6 months after an acute phase of pain . One international and two German good- quality prospect i ve studies have shown the predictive power of a maladaptive suppressive behaviour pattern . Based on the avoidance-endurance-model of pain chronification , both extreme and one-sided passive pain coping as well as one-sided suppressive coping modes were conceptualized as maladaptive due to the process of chronicity . We assume that extreme passive behaviour will lead to immobility and muscular atrophy . Neurophysiological processes of sensitization will further lead to the development of chronic pain . On the other h and , extreme suppressive behaviour will lead to an overuse of muscles and joints with a repetitive combination of muscular hyperactivity and pain . These repetitive pain experiences will also elicit neurophysiological processes of sensitization . ( 4 ) Psychosocial variables displayed more predictive power than biomedical or biomechanical factors . ( 5 ) Psychosocial factors may be used as predictors of the risk for developing long-term pain and disability . Mixed empirical evidence has been shown for the role of personality factors ( level C evidence ) and no support has been found for the idea of a " pain prone " personality disorder or for the role of sexual and physical abuse . DISCUSSION 20 years of research , several qualitative review s and a recently published systematic review of 37 good- quality prospect i ve studies regarding the role of psychological , biomedical , social and objective occupational factors in the process of chronicity of back pain revealed that psychological factors are significantly related to the onset of back pain as well as to the development of chronic pain . Furthermore , the psychological factors displayed more predictive power than biomedical or biomechanical variables . As a consequence for clinical practice , these psychological risk factors have to be considered as " yellow flags " if a back pain problem wo n't respond to medical treatment for more than four weeks . As a further consequence , special risk factor - based psychosocial interventions should be offered in addition to the medical treatment to patients with high psychological risk factors for the development of chronic pain . The efficacy of such an interdisciplinary care in the very early phases of back pain in order to prevent chronicity of pain and disability has been published recently by our group Objective Research studies focussing on the fear-avoidance beliefs model ( FABM ) have exp and ed considerably during the last years , however , there has been very little research directed at the elderly . The objective of the present study was to investigate the validity of the FABM in older patients with chronic low back pain ( CLBP ) . Method In a cross-sectional study , a group of elderly patients with CLBP ( N=103 ) was compared with an age-matched group of pain-free individuals ( N=59 ) to test the constructs inherent in the FABM . Constructs include  fear avoidance beliefs ( FABs ) , disability , disuse , and physical activity . In addition , the relationship of these constructs was also investigated in the patient group . CLBP- patients had an average age of 71.41 years ( SD=5.2 ) and pain-free individuals of 71.19 years ( SD=4.73 ) . Individuals participated in a photographed series of physical activities adapted to the age group ( Photograph Series of Daily Activities-German version for the elderly ) for the assessment of FAB , in the Hannover Disability Question naire , in the Freiburg Physical Activity Question naire , and in an ultrasound measurement to evaluate lumbar flexion . In addition , they completed an activity diary for 1 week . Before computation , the physical activity measurements were converted into metabolic units that characterize energy expenditure . Results In the patient group , FAB , pain intensity , and age predicted functional capacity , but not physical activity . Lumbar flexion was predicted by FAB and age . Patients were more fear-avoidant , reported more disability , and displayed less lumbar flexion than the pain-free individuals . No differences between the groups could be detected in regard to energy expenditure measured either by the question naire or by diary data . Conclusions The findings are consistent with results reported in the literature for younger age groups and confirm the assumption that the FABM is also valid for the elderly
target: Pooled data revealed no significant difference in the overall activity level of adults or adolescents with CLBP , however there is evidence that older adults with chronic low back pain are less active than controls .
  The results suggest that patients exhibit an altered pattern of physical activity over the course of a day compared to controls .
  There is no conclusive evidence that patients with chronic low back pain are less active than healthy individuals .
  Based on a limited number of studies , there is some evidence that the distribution of activities over the course of a day is different between patients with chronic low back pain and controls
background: BACKGROUND It is commonly assumed that patients with chronic low back pain are less active than healthy individuals .
  There has been a recent increase in the number of studies published comparing the physical activity levels of patients with chronic low back pain and healthy individuals .
  OBJECTIVES The aim of this systematic review was to determine , based on the current body of evidence , if patients with chronic low back pain have a lower level and /or altered pattern of physical activity compared with asymptomatic , healthy individuals .