Influence of Fear-Avoidance Beliefs on Functional Status Outcomes for People With Musculoskeletal Conditions of the Shoulder

Bhagwant S. Sindhu; Leigh A. Lehman; Sergey Tarima; Mark D. Bishop; Dennis L. Hart; Matthew R. Klein; Mikesh Shivakoti; Ying-Chih Wang

doi:10.2522/ptj.20110309

Figures

Figure 1.

Bar graph representing functional status change score (shoulder Computerized Adaptive Test [CAT] functional status score at discharge − shoulder CAT functional status score at intake) for people with low versus elevated fear-avoidance beliefs, without accounting for differences in subject effects, missing data, disease categories, clinics, and other confounding variables (asterisk indicates significance at alpha level of ≤.05).

Figure 2.

Average values with 95% confidence intervals for unadjusted estimates of mean differences between low versus elevated fear groups (low fear − elevated fear) on functional status change score (shoulder Computerized Adaptive Test [CAT] functional status score at discharge − shoulder CAT functional status score at intake) among 8 shoulder disease categories (asterisk indicates significance at alpha level of ≤.05). The category “Other musculoskeletal conditions” was created by combining dislocations (n=22), contusions (n=7), peripheral nerve disorders (n=6), and not otherwise classified musculoskeletal conditions (n=41) due to their very small sample size. Dashed line at zero indicates no difference between low and elevated fear groups on change in function. Average and 95% confidence interval of unadjusted estimates lying below zero indicate that change in function was greater for the elevated fear group than for the low fear group. Similarly, average and 95% confidence interval of unadjusted estimates lying above zero indicate change in function was greater for the low fear group than for the elevated fear group.

Figure 3.

Average values with 95% confidence intervals for adjusted estimates of mean differences between low and elevated fear groups (low fear − elevated fear) on functional status change score (shoulder Computerized Adaptive Test [CAT] functional status score at discharge − shoulder CAT functional status score at intake) among 8 shoulder disease categories (asterisk indicates significance at alpha level of ≤.05). The category “Other musculoskeletal conditions” was created by combining dislocations (n=22), contusions (n=7), peripheral nerve disorders (n=6), and not otherwise classified musculoskeletal conditions (n=41) due to their very small sample size. Dashed line at zero indicates no difference between low and elevated fear groups on change in function. Average and 95% confidence interval of adjusted estimates lying below zero indicate that change in function was greater for the elevated fear group than for the low fear group. Similarly, average and 95% confidence interval of adjusted estimates lying above zero indicate change in function was greater for the low fear group than for the elevated fear group.

Appendix.

Flow Diagram Used for Selecting Study Participants

Tables

Table 1.

Demographic and Health-Related Characteristics of Patients With Shoulder Impairments Who Had Low Versus Elevated Fear-Avoidance Beliefs^{^a}

↵^a ICD-9=International Classification of Diseases, Ninth Edition; CPT=Current Procedural Terminology.
^b Significance for differences between low versus elevated fear groups for various characteristics has not been calculated, as such significance will not be adjusted for random effects (clinics) and missing data and any reference to it will be misleading.
^c The category of “Other musculoskeletal conditions” was created by combining dislocations (n=22, ICD-9 code 831), contusions (n=7, ICD-9 code 923), peripheral nerve disorders (n=6, ICD-9 codes 353 and 953.4), and not otherwise classified musculoskeletal conditions (n=41) due to their very small sample size.

Table 2.

Results of Wald Statistics for Type 3 General Linear Model (GLM) Model With Functional Status Change Score as the Dependent Variable^{^a}

↵^a Only significant terms are reported.
^b CAT=Computerized Adaptive Test, pain observed=pain intensity change score was missing (ie, 0) vs pain intensity change score was reported (ie, 1), pain change observed=(pain intensity change score) × (pain observed), age group=18–44 years vs 45–64 years vs 65 years and older, duration of condition=acute (0–21 days) vs subacute (22–90 days) vs chronic (≥91 days), fear=low vs elevated fear-avoidance beliefs.
^c Inference of GLM regression parameters was performed using the Wald test statistic where the estimated parameter was compared with a chi-square distribution. The null hypothesis was no significant effect on change in function for a continuous variable and no significant difference in change in function between groups for a categorical variable.

Table 3.

Results of General Linear Model Unadjusted for and Adjusted for Other Confounders to Determine Differences in Functional Status Change Scores Between Low Fear Group and Elevated Fear Group for 8 Disease Categories

^a Significant at alpha level of .05.

Supplementary Data

Discussion Podcast: The Influence of Fear-Avoidance Beliefs on Patient Outcomes: How Much Influence—and What Are the Next Steps for Research?

Participants: Bhagwant Sindhu, PhD, OTR, Assistant Professor, Department of Occupational Science and Technology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin; Mark Bishop, PT, PhD, Assistant Professor, Department of Physical Therapy, University of Florida, Gainesville, Florida; and Julie Fritz, PT, PhD, ATC, Associate Professor, Department of Physical Therapy, University of Utah, and Clinical Outcomes Research Scientist, Intermountain Healthcare, Salt Lake City, Utah. Moderator: Chris Main, PhD, FBPsS, Editorial Board member, PTJ, and Professor of Clinical Psychology (Pain Management), Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, United Kingdom.

Files in this Data Supplement:

Discussion Podcast - A number of psychological factors-including pain catastrophizing, depression, general anxiety, fear, self-efficacy-appear to have an effect on rehabilitation outcomes. The size of this effect and the amount of influence of particular factors, however, are still unclear. The August 2012 PTJ article "Influence of Fear-Avoidance Beliefs on Functional Status Outcomes for People With Musculoskeletal Conditions of the Shoulder" reported that elevated fear-avoidance beliefs were associated with poorer outcomes in only 2 of 8 shoulder disease categories, and the effect was small. In this discussion podcast, 2 of the authors, Bhagwant Sindhu and Mark Bishop, join Julie Fritz and moderator Chris Main to discuss the implications of their study and the direction of future research on the influence of psychological factors on patient outcomes.
Running time: 20:32 (28.8 MB)

Discussion Podcast: The Influence of Fear-Avoidance Beliefs on Patient Outcomes: How Much Influence—and What Are the Next Steps for Research?

Length: 20:32

Quick Grabs

Bishop: "The way that I'm interpreting the condition and then talking to the patient about how I plan to proceed could be, in fact, some of the underpinning causes of what we saw in this data."

Sindhu: "When patients do take that cognitive approach, they tend to be better in terms of function."

Fritz: "Like most things in both practice and research, it's not as clear or as neat and tidy as the model might suggest."

References

Lentz TA, Barabas JA, Day T, Bishop MD, George SZ. The relationship of pain intensity, physical impairment, and pain-related fear to function in patients with shoulder pathology. J Orthop Sports Phys Ther. 2009;39:270-277.

Fritz JM, Beneciuk JM, George SZ. Relationship between categorization with the STarT Back Screening Tool and prognosis for people receiving physical therapy for low back pain. Phys Ther. 2011;91:722-732.

Hill JC, Dunn KM, Main CJ, Hay EM. Subgrouping low back pain: a comparison of the STarT Back Tool with the Örebro Musculoskeletal Pain Screening Questionnaire. Eur J Pain. 2010;14:83-89.

Hay EM, Dunn KM, Hill JC, et al. A randomised clinical trial of subgrouping and targeted treatment for low back pain compared with best current care: the STarT Back Trial Study Protocol. BMC Musculoskelet Disord. 2008;9:58.

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