Elsevier

Manual Therapy

Volume 13, Issue 3, June 2008, Pages 239-248
Manual Therapy

Original article
The use of fear-avoidance beliefs and nonorganic signs in predicting prolonged disability in patients with neck pain

https://doi.org/10.1016/j.math.2007.01.010Get rights and content

Abstract

Psychological factors, such as fear-avoidance beliefs and nonorganic signs, have been postulated to play a role in the development of prolonged disability. The purpose of this study was to determine if fear-avoidance beliefs and nonorganic behavior are predictive of disability in patients with neck pain. Seventy-nine patients, with neck pain, were recruited from five outpatient physiotherapy clinics. Each of the patients completed a modified Fear-Avoidance Beliefs Questionnaire (FABQ) and was evaluated for the presence of cervical nonorganic signs (CNOS). The FABQ consists of two subscales pertaining to work (FABQ-W) and physical activity (FABQ-PA). The patients also completed the Neck Disability Index (NDI) during the initial examination and 12 weeks later. A 12-week NDI score ⩾15 was operationally defined as prolonged disability. In order to determine the overall predictive ability of the FABQ and CNOS, receiver operator characteristic (ROC) curves were used. The areas under the ROC curve were 0.782 (CNOS), 0.833 (FABQ-Total), 0.782 (FABQ-W) and 0.814 (FABQ-PA). Results from this study suggest that the FABQ and testing for CNOS are both good tools for predicting patients who may develop prolonged disability.

Introduction

Neck pain, much like low back pain, is prone to chronicity and frequently results in prolonged disability (Makela et al., 1991; Pietri-Taleb et al., 1994). Moreover, the healthcare costs associated with this prolonged disability present a significant economic drain on society (Luo et al., 2004b) and pose a significant challenge to the healthcare provider. It has been suggested that, in addition to addressing the pathology and physical impairment of a condition, the healthcare provider should also consider the role that psychological factors play in the development of prolonged disability (Vlaeyen and Crombez, 1999; Luo et al., 2004a). It is now well recognized that many psychological factors are important determinants for risk of prolonged disability. Two such psychological factors, fear-avoidance beliefs and nonorganic signs, have received attention as predictors of prolonged disability in low back pain (Rose et al., 1992; Waddell et al., 1993; Klenerman et al., 1995; Karas et al., 1997; Crombez et al., 1999a, Crombez et al., 1999b; Vlaeyen and Crombez, 1999; Al-Obaidi et al., 2000; Fritz et al., 2001; Fishbain et al., 2003; Verbunt et al., 2003). However, these psychological factors have received relatively little attention for prolonged disability associated with neck pain.

The fear-avoidance model of exaggerated pain perception suggests that patients with an exaggerated fear of pain will avoid physical activities that are anticipated to cause or increase pain (Lethem et al., 1983; Slade et al., 1983). This model proposes that there is a normal balance between sensation and emotion that occur with injury or disease. However, when this balance becomes disrupted, it can lead to prolonged disability. This maladaptive coping strategy (i.e. exaggerated fear leading to avoidance of physical activities) may stimulate self-imposed immobilization which may potentiate the fibrosis and atrophy of the underlying injury. In addition, these patients may be less likely to engage in movement-related activities that promote healing and recovery. It has been said that this fear of pain is actually more disabling than the condition itself (Waddell et al., 1993; Crombez et al., 1999b).

While research has suggested that a relationship exists between fear-avoidance beliefs and the chronicity of low back pain, there have been only a couple of studies that have specifically investigated fear-avoidance beliefs with cervical neck pain. Nederhand et al. (2004) found that fear-avoidance beliefs were predictive of chronic neck pain disability. However, George et al. (2001) reported a weak association between fear-avoidance beliefs and disability for those with chronic cervical pain. Thus, the relationship between fear-avoidance beliefs and neck-related disability at the present is inconclusive.

Another psychological factor, unrelated conceptually to fear-avoidance beliefs, that has received considerable attention in the literature is the concept of nonorganic signs. Nonorganic signs are findings, during a patient examination, that are suggestive of a physical illness or disease for which there is no demonstrable organic cause or physiological dysfunction. Simply put, nonorganic signs are findings that do not seem to be consistent with the nature of a particular pathology. In contrast, organic signs are findings that are consistent with the presence of pathology or disease. Intuitively, patients presenting with musculoskeletal dysfunction (e.g. neck pain) most commonly present with organic signs. However, occasionally a patient will, in addition to organic signs, exhibit nonorganic signs (i.e. signs not consistent with organic pathology). A high nonorganic presentation may be suggestive of psychological factors related to abnormal illness behavior, which may predispose the patient to a protracted recovery.

The presence of a high nonorganic sign component in a patient with low back pain is thought to be indicative of psychological distress (Waddell et al., 1984, Waddell et al., 1989; Main et al., 1992; Novy et al., 1998). Nonorganic signs have been reported to have a consistent correlation with the ‘neurotic triad’ (hypochondriasis, depression and hysteria scales) of the Minnesota Multiphasic Personality Inventory (Waddell et al., 1980; Novy et al., 1998). In addition, nonorganic signs have been shown to identify patients with chronic low back pain who may be depressed or anxious (Weaver et al., 2003/2004). More importantly, from a healthcare perspective, the presence of a high nonorganic component has been linked to prolonged disability (Waddell et al., 1980; Klenerman et al., 1995) and negative treatment outcomes (McCulloch, 1977; Waddell et al., 1980, Waddell et al., 1986; Lehmann et al., 1983; Dzioba and Doxey, 1984; Doxey et al., 1988; Werneke et al., 1993). Waddell et al. (1980) found a correlation between nonorganic signs and a number of treatment outcomes, including work loss, treatment failure, poor postsurgical results, and disability in patients with low back pain. Waddell and Main (1987) reported that nonorganic signs were found more frequently in patients with chronic low back pain as compared to those with shorter symptom duration. They also found that NOS were more prevalent in those with failed treatment. In addition, a number of other researchers have reported a correlation between NOS and poor return to work outcomes (Vallfors, 1985; Lancourt and Kettelhut, 1992; Werneke et al., 1993; Gaines and Hegmann, 1999).

Until recently, there has been no standardized method for assessing nonorganic signs in patients with neck pain. In 2000, Sobel et al. (2000) developed and standardized nonorganic signs for cervical spine pain. These cervical nonorganic signs (CNOS) were patterned after the nonorganic signs for low back pain that were originally described by Waddell et al. (1980). While Sobel et al. (2000) reported good inter-rater reliability of CNOS, there have been no studies that have examined any aspects of validity of these signs in patients with neck pain.

The purpose of this study was to determine if two different psychological factors (i.e. fear-avoidance beliefs and nonorganic behavior), both of which have been shown to be related to disability in low back pain, played a role in prolonged disability in patients with neck pain. If an association between these psychological factors and disability can be established, it will offer some initial evidence to the validity of these measures for patients with neck pain. As Waddell et al. (1980) originally noted, the final proof of the validity of nonorganic signs (and, logically fear-avoidance beliefs) rests on their ability to predict outcome. In order to determine the role that fear-avoidance beliefs and nonorganic behavior play in prolonged neck disability, two research questions were considered: 1. Are fear-avoidance beliefs and nonorganic behavior predictive of prolonged disability in patients with neck pain? and 2. Which of the cut-off values for fear-avoidance beliefs and nonorganic behavior maximizes prediction of prolonged disability of neck pain?

Section snippets

Patients

Seventy-nine consecutive patients with neck pain (males=23, females=56) aged 19–71 (mean=49.6, SD=12.7), presenting to five outpatient physiotherapy clinics were recruited to participate in this study. Of this total, 5 were acute (7 days or less since the onset of pain), 18 were sub-acute (between 8 days and 7 weeks since the onset of pain), and 56 were chronic (more than 7 weeks since the onset of pain). Because the entry point of patients to outpatient physiotherapy occurs at various stages

Results

Sensitivity, specificity, likelihood ratio, and posttest probability values were calculated for each possible cut-off score for each of the variables (FABQ-T, FABQ-W, FABQ-PA, and CNOS) for the overall sample and broken down into the acute/sub-acute and chronic sub-samples (Table 2). Of the 79 patients for the overall sample, 29 would go on to develop prolonged disability (60.4% pretest probability). The areas under the ROC curves for the FABQ variables for the overall sample were 0.833 (95%

Discussion

These results provide evidence that the presence of prolonged disability in patients with neck pain is at least partially influenced by fear-avoidance beliefs and nonorganic behavior. More specifically, these results indicate that the higher the level of fear-avoidance beliefs, the higher the risk of prolonged disability. Additionally, a high nonorganic presentation is associated with a higher risk for prolonged disability. In the least, these results offer evidence of the predictive validity

Conclusion

Results of this study support the predictive validity of CNOS and the FABQ in patients with neck pain. Importantly, these tests provide valuable clinical information in identifying patients with neck pain who are at risk for prolonged disability. Identification of these patients early in the process can lead to improved clinical decision making by facilitating treatment options that will best address the physical and psychological impairment of the patient.

References (58)

  • M.J. Nederhand et al.

    Chronic neck pain disability due to an acute whiplash injury

    Pain

    (2003)
  • M.J. Nederhand et al.

    Predictive value of fear avoidance in developing chronic neck pain disability: consequences for clinical decision making

    Archives of Physical Medicine and Rehabilitation

    (2004)
  • D.M. Novy et al.

    Waddell signs: distribution properties and correlates

    Archives of Physical Medicine and Rehabilitation

    (1998)
  • F. Pietri-Taleb et al.

    Longitudinal study on the role of personality characteristics and psychological distress in neck trouble among working men

    Pain

    (1994)
  • M.J. Rose et al.

    An application of the fear avoidance model to three chronic pain problems

    Behaviour Research and Therapy

    (1992)
  • J.M. Sieben et al.

    Pain-related fear at the start of a new low back pain episode

    European Journal of Pain

    (2005)
  • J.M. Sieben et al.

    A longitudinal study on the predictive validity of the fear-avoidance model in low back pain

    Pain

    (2005)
  • P.D. Slade et al.

    The fear-avoidance model of exaggerated pain perception—II

    Behaviour Research and Therapy

    (1983)
  • J.B. Sobel et al.

    Cervical nonorganic signs: a new clinical tool to assess abnormal illness behavior in neck pain patients: a pilot study

    Archives of Physical Medicine and Rehabilitation

    (2000)
  • J.A. Verbunt et al.

    Fear of injury and physical deconditioning in patients with chronic low back pain

    Archives of Physical Medicine and Rehabilitation

    (2003)
  • J.A. Verbunt et al.

    Decline in physical activity, disability and pain-related fear in sub-acute low back pain

    European Journal of Pain

    (2005)
  • J.W. Vlaeyen et al.

    Fear of movement/(re)injury, avoidance and pain disability in chronic low back pain patients

    Manual Therapy

    (1999)
  • G. Waddell et al.

    Clinical assessment and interpretation of abnormal illness behaviour in low back pain

    Pain

    (1989)
  • G. Waddell et al.

    A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability

    Pain

    (1993)
  • S.M. Al-Obaidi et al.

    The role of anticipation and fear of pain in the persistence of avoidance behavior in patients with chronic low back pain

    Spine

    (2000)
  • K. Boersma et al.

    Screening to identify patients at risk: profiles of psychological risk factors for early intervention

    Clinical Journal of Pain

    (2005)
  • Boersma K, Linton SJ. Expectancy, fear and pain in the prediction of chronic pain and disability: a prospective...
  • A.K. Burton et al.

    Information and advice to patients with back pain can have a positive effect. A randomized controlled trial of a novel educational booklet in primary care

    Spine

    (1999)
  • M. Curatolo et al.

    Central hypersensitivity in chronic pain after whiplash injury

    Clinical Journal of Pain

    (2001)
  • Cited by (0)

    View full text