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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.

Research studies focusing on the fear-avoidance model have expanded considerably since the review by Vlaeyen and Linton (Vlaeyen J. W. S. & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain, 85(3), 317--332). The fear-avoidance model is a cognitive-behavioral account that explains why a minority of acute low back pain sufferers develop a chronic pain problem. This paper reviews the current state of scientific evidence for the individual components of the model: pain severity, pain catastrophizing, attention to pain, escape/avoidance behavior, disability, disuse, and vulnerabilities. Furthermore, support for the contribution of pain-related fear in the inception of low back pain, the development of chronic low back pain from an acute episode, and the maintenance of enduring pain, will be highlighted. Finally, available evidence on recent clinical applications is provided, and unresolved issues that need further exploration are discussed.

Background: The Athlete Fear-Avoidance Questionnaire (AFAQ) is a validated instrument that measures athletes’ fear and avoidance behaviors after an injury, particularly regarding their sporting activities. Purpose: This study aimed to adapt and validate the AFAQ for Arabic-speaking recreational players (AFAQ-Arabic) after anterior cruciate ligament reconstruction (ACLR). Study Design: Cohort study; level of evidence: 3. Methods: The AFAQ underwent translation and cross-cultural adaptation according to the Beaton guidelines. A total of 104 male recreational players who had undergone ACLR completed the AFAQ-Arabic, the Fear-Avoidance Belief Questionnaire (FABQ), and the Numerical Pain Scale (NPS). To assess test-retest reliability, a subset of 38 recreational players were asked to complete the AFAQ-Arabic twice, 1 week apart. Statistical tests were conducted to test the internal consistency, reliability, and convergent validity of the AFAQ-Arabic. Results: The AFAQ-Arabic demonstrated high internal consistency (Cronbach alpha, 0.854) and excellent test-retest reliability (intraclass correlation coefficient, 0.885) (95% CI, 0.784-0.942; P < .001). Minimal floor (4.8% scoring the minimum) and ceiling effects (1% scoring the maximum) were observed. Convergent validity showed significant positive weak correlations between the AFAQ-Arabic and (1) the FABQ-Physical Activity (r = 0.340; P < .01), (2) the FABQ-Work (r = 0.272; P < .01), and (3) the NPS (r = 0.383; P < .01). Cross-cultural adaptation of the AFAQ-Arabic revealed linguistic and cultural relevance. Conclusion: Our study demonstrated that the AFAQ-Arabic was a reliable and valid tool for assessing fear avoidance in Arabic-speaking recreational players after ACLR. Future studies are needed to measure athlete fear-avoidance in injured Arabic-speaking athletes to understand its psychological aspects in rehabilitation and potentially aid in tailored interventions for improving outcomes.

A growing number of studies have identified high rates of pediatric chronic postsurgical pain (CPSP) after major surgery. Pediatric CPSP is associated with pain-related distress and comorbid mental health outcomes, such as anxiety and depression. From a biopsychosocial perspective, youth factors, such as genetics, epigenetics, sex, presurgical pain, sleep, anxiety, and pain catastrophizing, as well as parent factors, such as cognitive appraisals of their child's pain expression and pain catastrophizing, converge and lead to chronic pain disability. A comprehensive and testable psychosocial model of the transition from acute to chronic pediatric postsurgical pain has not been developed. This narrative review begins by evaluating the epidemiology and trajectories of pediatric CPSP and moves on to examine the more influential psychosocial models that have been proposed to understand the development of pediatric CPSP. Much of the literature to date has been conducted on adolescents undergoing spinal fusion. To conceptualize the transition from acute to chronic pain in youth, a combined diathesis-stress and interpersonal fear avoidance model is presented. Novel areas of future research include the potential influence that siblings and peers have on a youth's development of CPSP as well as the influence of gender.

ObjectiveThis study aimed to evaluate the effectiveness of an early ambulation program based on cognitive behavioral therapy for elderly patients with kinesiophobia after Total hip arthroplasty (THA).MethodsA quasi-experimental study design was adopted. Elderly patients with post-THA kinesiophobia admitted between December 2023 and December 2024 were enrolled and divided into a control group and an intervention group. The control group received routine health education and rehabilitation training. Whereas the intervention group received a cognitive-behavioral therapy-based early mobilization program. Postoperative data were collected, including the time of first ambulation kinesiophobia scores, pain scores, Harris scores, ADL scores. Postoperative follow-up of the patient’s kinesiophobia, pain, Harris, ADL scores was conducted at one and 3 months. Statistical analysis was conducted using t-test, analysis of variance and chi-square.ResultsBaseline characteristics were comparable between the two groups. The intervention group demonstrated a significantly shorter time to first ambulation compared to the control group. Kinesiophobia scores improved significantly over the three postoperative time points assessed. Pain scores, Harris scores, and ADL scores also showed significant improvements. Additionally, the intervention group had a significantly shorter hospital stay and lower hospitalization costs.ConclusionThe CBT-based early mobilization intervention effectively improved health outcomes in elderly patients with post-THA kinesiophobia, offering valuable insights for clinical practice.Clinical trial registrationhttp://www.chictr.org.cn/showproj.aspx?proj=2400094636&lang=en, Identifier ChiCTR2400094636.

It is well known that exercise produces analgesic effects (exercise-induced hypoalgesia (EIH)) in animal models and chronic pain patients, but the brain mechanisms underlying these EIH effects, especially concerning the emotional aspects of pain, are not yet fully understood. In this review, we describe drastic changes in the mesocorticolimbic system of the brain which permit the induction of EIH effects. The amygdala (Amyg) is a critical node for the regulation of emotions, such as fear and anxiety, which are closely associated with chronic pain. In our recent studies using neuropathic pain (NPP) model mice, we extensively examined the association between the Amyg and EIH effects. We found that voluntary exercise (VE) activated glutamate (Glu) neurons in the medial basal Amyg projecting to the nucleus accumbens (NAc) lateral shell, while it almost completely suppressed NPP-induced activation of GABA neurons in the central nucleus of the Amyg (CeA). Furthermore, VE significantly inhibited activation of pyramidal neurons in the ventral hippocampus-CA1 region, which play important roles in contextual fear conditioning and the retrieval of fear memory. This review describes novel information concerning the brain mechanisms underlying EIH effects as a result of overcoming the fear-avoidance belief of chronic pain.

Patellofemoral pain (PFP) is a common musculoskeletal condition, which has a negative effect on physical activity and function. Currently, it is unknown how and why individuals with PFP modify their physical activity. The purpose of this qualitative study was to explore the experience of knee pain on physical activity and everyday life in individuals experiencing PFP. Qualitative phenomenological interview study. University. Sixteen patients experiencing PFP. Semi-structured interviews were used to explore the pain experience on physical activity and daily living. Patients with PFP attempted various strategies to remain physically active, such as identifying pain thresholds, activity modification, and pushing through their pain. Despite these various strategies to stay active, pain influenced their social life and patients demonstrated both fear avoidance beliefs and pain catastrophizing. Patients with PFP also reported barriers to seek care for their knee pain, such as negative past experiences with health care professionals and care not aligned with the best evidence available. Clinicians treating PFP should be aware of biologic, psychological, and social aspects when evaluating and intervening with patients. •Individuals with PFP employ various strategies to remain physically active.•Pain thresholds are often established as a strategy to minimize painful tasks.•PFP negatively impacts physical activity, daily activities, and their social life.

Fear avoidance behavior is related to symptom persistence and disability in various health conditions, such as chronic pain. Fear avoidance behavior also may impact recovery from mild traumatic brain injury (mTBI), but no measure of this construct has been psychometrically validated for the mTBI population. Adults who sustained an mTBI (n = 159) were recruited from three outpatient mTBI clinics. Participants completed the new Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI). The FAB-TBI includes 16 items drawn from well-established fear avoidance scales, primarily in the chronic pain literature. An exploratory factor analysis and Rasch analysis were conducted to evaluate the factor structure, dimensionality, and differential item functioning of the FAB-TBI. The FAB-TBI scale was found to have strong internal consistency (Cronbach's α = 0.9). Exploratory factor analysis suggested at least two distinct factors (activity avoidance and cogniphobia). Initial fit to the Rasch model was adequate, with one misfitting item. The model was not improved after removing the misfitting item. Best fit to the unidimensional Rasch model was achieved after items were combined into three super items based on exploratory factor analysis and retaining the misfitting item χ2(6, n = 159) = 2.1, p = 0.06). The FAB-TBI appears to be a psychometrically sound measure of fear avoidance behavior after mTBI. Conversion tables are made available to convert scores into interval-level data for future research.

Patellofemoral pain (PFP) is a common source of knee pain in active individuals, accounting for a large number of knee injuries examined in sports medicine clinics. As a chronic condition, PFP can affect mental health. However, this effect has not yet been studied in individuals with PFP. To determine how subjective physical and mental health measures in individuals with PFP differed from those measures in pain-free individuals. Case-control study. Laboratory. Volunteers for the study were 30 people with PFP (19 women, 11 men; age = 20.23 ± 3.32 years, height = 166.69 ± 6.41 cm, mass = 69.55 ± 13.15 kg) and 30 matched pain-free individuals (19 women, 11 men; age = 20.33 ± 3.37 years, height = 169.31 ± 9.30 cm, mass = 64.02 ± 11.00 kg). Current and worst pain levels in the past 24 hours were determined using a visual analog scale (VAS). The Anterior Knee Pain Scale, Fear Avoidance Belief Questionnaire, and Lower Extremity Functional Scale were administered. Physical and mental health measures were obtained using a modified 12-item Short Form Health Survey. Scores for 2 subscales on the modified Short Form-12 were weighted and calculated: physical component and mental component.Independent t tests were calculated to compare variables between groups. Coefficient correlations were used to measure the associations between the variables. Individuals with PFP reported lower levels of physical (pain free: 56.13 ± 1.63, PFP: 50.54 ± 7.10, P < .001) and mental (pain-free: 53.32 ± 4.71, PFP: 48.64 ± 10.53, P = .03) health. In the PFP group, we found moderate negative correlations between the VAS score for current pain and mental health (r = -0.52, P < .01) and between the VAS score for worst pain in the past 24 hours and mental health (r = -0.46, P = .01) and between activity limitations in individuals with PFP and fear avoidance beliefs (r = -0.61, P < .01). Our results should encourage clinicians, especially musculoskeletal rehabilitation professionals, to acknowledge the importance of a whole-person approach when treating or planning rehabilitation programs for individuals with PFP.

Purpose Fear of reinjury is an important factor in determining who returns to sport following anterior cruciate ligament reconstruction (ACLR). Evidence from other musculoskeletal injuries indicates fear of reinjury may be related to stiffened movement patterns observed in individuals following ACLR. The relationship between fear of reinjury and performance on dynamic tasks, however, has not been investigated. Therefore, the purpose of this study was to investigate the relationship between fear of reinjury and jump-landing biomechanics. Methods Thirty-six females (height = 168.7 ± 6.5 cm, body mass = 67.2 ± 10.0 kg, age = 18.9 ± 1.5 years) with a history of ACLR (time from surgery = 26.1 ± 13.3 months) participated in the study. Each participant performed five trials of a standard jump-landing task. 3D motion capture and surface electromyography was used to record peak kinematics and lower extremity muscle activation on the injured limb during the jump landings. Spearman’s rank correlations established the relationship between TSK-11 scores and each biomechanical variable of interest. Results There was a significant, negative relationship between fear of reinjury (TSK-11: 19.9 ± 4.5) and knee ( p  = 0.006), hip ( p  = 0.003), and trunk flexion ( p  = 0.013). There was also a significant, positive relationship between hip adduction ( p  = 0.007), and gluteus maximus preparatory activation ( p  = 0.001). Conclusions The results of this study indicate that higher fear of reinjury is associated with stiffened movement patterns that are associated with increased risk of a second ACL injury. Similar movement patterns have been observed in patients with low back pain. Clinicians should evaluate psychological and emotional consequences of injury in addition to the physical consequences as they appear to be related. Level of evidence III.