Are we "fear-avoidant"?
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Chronic Disease↗
Biomedical subjects
Steven J Linton
Publications and source records attributed to Steven J Linton.
Psychological mechanisms in the maintenance of insomnia: arousal, distress, and sleep-related beliefs.
The purpose of this study was to examine whether arousal, distress, and sleep-related beliefs are related to the maintenance of insomnia. From a randomly selected sample from the general population (n=3600), 1936 participants filled out a baseline and 1-year follow-up survey. Logistic regressions were used to investigate whether arousal, distress, and beliefs were related to sleep status (insomnia: n=116; poor sleep: n=222; normal sleep: n=529; good sleep: n=234) over 1 year. Cluster analysis was employed to assess whether it was possible to classify the participants based on their profiles of psychological functioning. The results showed that beliefs in the long-term negative consequences of insomnia, anxiety, depression, and arousal were significantly related to the maintenance of insomnia (18-72% of the variance). Of the individuals with persistent insomnia, 91% belonged to a cluster characterized by high scores on sleep-related beliefs, anxiety, depression, and arousal, and 9% to a cluster defined by low scores on the mechanisms. This study shows that sleep-related beliefs, anxiety, depression, and arousal are related to the maintenance of persistent insomnia, but also that these mechanisms often co-occur in individuals with insomnia.
Adult↗
A 5-year follow-up evaluation of the health and economic consequences of an early cognitive behavioral intervention for back pain: a randomized, controlled trial.
STUDY DESIGN: A 5-year follow-up of a randomized, controlled trial. OBJECTIVE: To evaluate the long-term health and economic consequences of a cognitive behavioral intervention. SUMMARY OF BACKGROUND DATA: Linton and Andersson (Spine 2000;25:2825-31) provide 1 of only a few studies on the preventive effects of a cognitive behavioral intervention. The present study is a 5-year follow-up. METHODS: In the original study, 213 participants were randomized to the cognitive-behavioral group intervention or to usual care plus information on self-care (information comparison group). Of participants, 97% completed a follow-up questionnaire 5 years after the intervention, and supplemental records were obtained from the National Insurance Authority. RESULTS: The cognitive behavioral group had significantly less pain, was more active, enjoyed better quality of life, and had better general health relative to the information comparison group. There was no difference on health care use. The risk of long-term sick leave was 3 times higher in the information comparison group. The cognitive behavioral group had significantly less lost productivity costs and a lower total cost/y/person (16,514 Swedish kronor) compared to the information comparison group (45,990 Swedish kronor). CONCLUSIONS: A cognitive-behavioral group intervention produces long-term health and economic benefits. Usual medical care might be improved considerably by implementing these psychologic methods.
Back Pain↗
Psychosocial work stressors in the development and maintenance of insomnia: a prospective study.
This study is aimed at examining whether psychosocial work stressors are related to the development and maintenance of insomnia. A prospective design was used with a baseline and a 1-year follow-up questionnaire (N = 1,530). The results showed that among individuals with no insomnia at baseline, high work demands increased the risk of developing insomnia 1 year later. Among participants with insomnia at baseline, high leader support decreased the risk of still reporting insomnia at follow-up. Finally, low influence over decisions and high work demands were related to the maintenance of insomnia. The results indicate that perceived work stressors are related to the development and maintenance of insomnia. This might have implications for how insomnia is conceptualized as it places work stressors in the model and for how interventions at different stages of insomnia are implemented.
Adult↗
Psychological processes underlying the development of a chronic pain problem: a prospective study of the relationship between profiles of psychological variables in the fear-avoidance model and disability.
OBJECTIVES: Understanding the psychological processes that underlie the development of a chronic pain problem is important to improve prevention and treatment. The aim of this study was to test whether distinct profiles of variables within the fear-avoidance model could be identified and could be related to disability in a meaningful way. METHODS: In 81 persons with a musculoskeletal pain problem, cluster analysis was used to identify subgroups with similar patterns on fear and avoidance beliefs, catastrophizing, and depression. The clusters were examined cross-sectionally and prospectively on function, pain, health care usage, and sick leave. RESULTS: Five distinct profiles were found: pain-related fear, pain-related fear + depressed mood, medium pain-related fear, depressed mood, and low risk. These subgroups were clearly related to outcome. In contrast to the clusters "medium pain-related fear" and "low risk," the majority of those classified in the clusters "pain-related fear," "pain-related fear + depressed mood," and "depressed mood" reported long-term sick leave during follow-up. The subjects in the clusters with high scores on the depression measure reported the highest percentage of health care usage during follow-up (70% in the "pain-related fear + depressed mood" group and 42% in the "depressed mood" group reported >10 health care visits). CONCLUSIONS: Distinct profiles of psychological functioning could be extracted and meaningfully related to future disability. These profiles give support to the fear-avoidance model and underscore the need to address the psychological aspects of the pain experience early on.
Adaptation, Psychological↗
Burnout in the working population: relations to psychosocial work factors.
This study investigated levels of burnout in the general population irrespective of occupation and relations between burnout and psychosocial work factors. A cross-sectional survey featuring sleep problems, psychological distress, burnout (Maslach Burnout Inventory-General Survey), and psychosocial factors at work, was mailed to a random sample of 3,000 participants, aged 20-60. Response rate was 61%. A high level (18%), a low level (19%), and an intermediate group (63%) for burnout were constructed. The high level group was associated with those who were > 50 years old, women, those experiencing psychological distress, and those with a poor psychosocial work climate. The analyses on variables significant in previous analyses showed that the high level group was strongly related to high demands, low control, lack of social support, and disagreeing about values at the workplace even when accounting for age, gender, and psychological distress. We conclude that psychosocial work factors are important in association to burnout regardless of occupation.
Adult↗
The development of insomnia within the first year: a focus on worry.
OBJECTIVES: The aim of this investigation was to study the relationships between sleep-related worry and subjective sleep perception as a function of stage of chronicity. DESIGN: A cross-sectional study consisting of 136 individuals with a short history of insomnia was used. METHODS: The 136 participants were grouped to form two different levels of chronicity based on their duration of insomnia: short (3-7 months; n=69) and long (>7-12 months; n=67). Two domains of sleep-related worry (sleeplessness and health) were used as predictors of subjective sleep perception (sleep onset latency, time awake after sleep onset, and total sleep time). RESULTS: The association between worry for sleeplessness and subjective sleep perception was significantly different across the stages of chronicity. In the group with a short duration of insomnia, worry for sleeplessness was not related to subjective sleep perception. Worry for sleeplessness was however a significant predictor of subjective sleep perception in the group with a long duration of insomnia (unique variance: 33% on sleep onset latency, 19% on time awake after sleep onset, and 13% on total sleep time). Even if marked differences were observed between the two groups, worry for health was not significantly different across stages of chronicity on subjective sleep perception. CONCLUSIONS: This suggests that the role of sleep-related worry to subjective sleep perception may increase over time. Given that worry was a mechanism with an increasingly stronger impact over time, this supports the idea that worry is a potential mechanism related to the development of insomnia.
Adolescent↗
Expectancy, fear and pain in the prediction of chronic pain and disability: a prospective analysis.
Studies with (sub) acute back pain patients show that negative expectancies predict pain and disability at a one-year follow up. Yet, it is not clear how expectations relate to other factors in the development of chronic disability such as pain and fear. This study investigates the relationship between expectations, pain-related fear and pain and studies how these variables are related to the development of chronic pain and disability. Subjects (N = 141) with back and/or neck pain (duration <1 year) were recruited via primary care. They completed measures on pain, expectancy, pain-related fear (pain-related negative affect and fear avoidance beliefs) and function. A one-year follow up was conducted with regard to pain and function. It was found that pain, expectancy, pain-related fear and function were strongly interrelated. In the cross-sectional analyses negative expectancies were best explained by frequent pain and a belief in an underlying and serious medical problem. Prospectively, negative expectancy, negative affect and a belief that activity may result in (re) injury or increased pain, explained unique variance in both pain and function at one-year follow up. In conclusion, expectancy, negative affect and fear avoidance beliefs are interrelated constructs that have predictive value for future pain and disability. Clinically, it can be helpful to inquire about beliefs, expectancy and distress as an indication of risk as well as to guide intervention. However, the strong interrelations between the variables call for precaution in treating them as if they were separate entities existing in reality.
Adult↗
How does persistent pain develop? An analysis of the relationship between psychological variables, pain and function across stages of chronicity.
The fear-avoidance model is an attempt to underscore the importance of cognitive and behavioral factors, in a chain of events linking pain to disability. However, it is not clear at what time point the psychological variables within the model begin to be prominent. The aim of this study was to investigate the role of these psychological variables in the development of a chronic musculoskeletal pain problem. Three stages of chronicity, defined by duration of pain, provided a proxy for the developmental process: <1 year (N=48), 1-3 years (N=47) and >3 years (N=89). Subjects completed questionnaires on fear of movement, catastrophizing, depression, pain and function. The results indicate that the relationship between fear of movement and function is moderated by the stage of chronicity. Regression analyses showed that fear of movement did not explain any variance in the group with pain duration <1 year. Fear of movement did explain variance in the groups with pain duration of 1-3 years and >3 years. This suggests that the time point in the development of a musculoskeletal pain problem might be an essential aspect of the importance of the relationship between psychological components and function.
Adult↗
Do evidence-based guidelines have an impact in primary care? A cross-sectional study of Swedish physicians and physiotherapists.
STUDY DESIGN: A cross-sectional study of physicians and physiotherapists in primary care. OBJECTIVES: To survey how familiar clinicians were with evidence-based guidelines for back pain and their opinion about their clinical usefulness and to compare self-reported practice behavior with the guidelines. SUMMARY OF BACKGROUND DATA: Guidelines, based on empirical evidence, are meant to ensure that patients get the most effective treatment. These evidence-based guidelines should steer clinical praxis, but clinicians may not read, let alone heed, them. METHODS: Using a questionnaire, the authors surveyed all physicians and physiotherapists in primary health care in Orebro County, Sweden (N = 235). RESULTS: Forty-two percent of the physicians and 37% of the physiotherapists were unfamiliar with the content of the guidelines, and 40% of the physicians and 25% of the physiotherapists were unfamiliar with the concept of 'red flags.' Less than half of the clinicians, 47%, were familiar both with the content of the guidelines and the concept of red flags. Their opinion about the guidelines showed that 54% of the physicians and 56% of the physiotherapists agreed that the guidelines were useful in clinical praxis. Concerning the self-reported practice behavior, the majority indicated that they followed the key points in the guidelines. CONCLUSIONS: A relatively large proportion of clinicians were unfamiliar with the content of evidence-based guidelines and/or with the concept of red flags. The process of implementing research into clinical practice is in need of an overhaul, and the impact of guidelines on clinical practice may be questioned.
Adult↗
Cognitive-behavioral group therapy as an early intervention for insomnia: a randomized controlled trial.
A randomized controlled design was used with a 1-yr follow-up. The purpose was to compare the effects of two early interventions, a cognitive-behavioral group intervention and a self-help information package, in patients with insomnia. In sum, 165 individuals seeking care for insomnia of 3-12 months duration were randomized to either a group receiving a CBT intervention or a group receiving a self-help information package. At the 1-yr follow-up, 136 participants had completed the entire study. At the 1-yr follow-up, the CBT group intervention was, compared with the control group, effective in producing reductions in dysfunctional beliefs and attitudes about sleep, negative daytime symptoms, as well as vital improvements in sleep (i.e. sleep onset latency, time awake after sleep onset, total sleep time, sleep quality, and sleep efficiency). In comparison with the control group, significantly more participants in the CBT group met criteria at the 1-yr follow-up for clinically meaningful improvements in sleep onset latency, time awake after sleep onset, and sleep efficiency. A CBT group intervention may well be a viable early intervention for patients with insomnia in a wide range of health services.
Adolescent↗
Improving return to work research.
BACKGROUND: Despite considerable multidisciplinary research on return to work (RTW), there has been only modest progress in implementation of study results, and little change in overall rates of work disability in developed countries. METHODS: Thirty RTW researchers, representing over 20 institutions, assembled to review the current state of the art in RTW research, to identify promising areas for further development, and to provide direction for future investigations. RESULTS AND CONCLUSION: Six major themes were selected as priority areas: early risk prediction; psychosocial, behavioral and cognitive interventions; physical treatments; the challenge of implementing evidence in the workplace context; effective methods to engage multiple stakeholders; and identification of outcomes that are relevant to both RTW stakeholders and different phases of the RTW process. Understanding and preventing delayed RTW will require application of new concepts and study designs, better measures of determinants and outcomes, and more translational research. Greater stakeholder involvement and commitment, and methods to address the unique challenges of each situation are required.
Humans↗
Prognosis and the identification of workers risking disability: research issues and directions for future research.
INTRODUCTION: Screening procedures based on prognostic data are an important prerequisite for prevention of disability due to low-back pain. This paper reviews the research on prognosis to delineate the most pertinent research challenges, and outlines directions for future research to improve the scientific quality and screening accuracy of prognostic efforts. METHODS: Reviews of prognosis research were examined to identify key methodological and research issues. RESULTS: Certain issues such as sampling procedures, research designs, data analyses, prognostic indicators, and follow-up procedures limit the value of prior studies. Absence of a clear conceptual framework hampers interpretation of findings and moving research questions forward. The recurrent nature of back pain and the need to effectively include the impact of employer actions and the job market were also identified as significant issues. CONCLUSIONS: Future research will be enhanced by addressing conceptual and definitional issues, applying tested and sensible measures, and careful follow-up of the study population.
Actuarial Analysis↗
Integrating psychosocial and behavioral interventions to achieve optimal rehabilitation outcomes.
INTRODUCTION: Psychosocial factors are important contributors to work disability associated with musculoskeletal conditions. The primary objectives of this paper were 1) to describe different psychosocial interventions that have been developed to prevent prolonged work disability, and 2) to identify future research directions that might enhance the impact of programs targeting psychosocial risk factors for work disability. METHODS: Selective review of scientific literature on psychosocial and behavioral interventions and work disability. RESULTS: Most prior interventions focused on psychosocial risk factors that exist primarily within the individual (e.g., pain catastrophizing, beliefs, expectancies). Successful disability prevention will require methods to assess and target psychosocial risk factors "outside" of the individual (e.g., interpersonal conflict in the workplace, job stress, etc.) using cost-effective, multipronged approaches. Research to explore interactions among different domains of psychosocial risk factors in relation to RTW outcomes is needed. Challenges to effective secondary prevention of work disability include developing competencies to enable a range of providers to deliver interventions, standardization of psychosocial interventions, and maximizing adherence to intervention protocols. CONCLUSION: Effective secondary prevention of work disability will require research to develop cost-effective, multipronged approaches that concurrently target both worker-related and workplace psychosocial risk factors.
Adaptation, Psychological↗
Does work stress predict insomnia? A prospective study.
OBJECTIVES: The aim of this study was to investigate the one-year development of self-reported sleep problems in workers with no sleep problem at baseline, and to evaluate the role of work stress in the etiology of a new episode. DESIGN: A prospective design was employed. METHODS: A total of 816 employees with no sleeping problems during the past three months completed a baseline questionnaire concerning their general health, working hours and working conditions. One year later they were contacted again to ascertain whether they were experiencing problems sleeping. RESULTS: At the follow-up, the three-month point prevalence of self-reported sleep problems for this population was 14.3%. While controlling for age and gender, it was found that irregular working hours and general health were not significantly related to the development of a new episode of sleeping problems. However, stress in the form of a 'poor' psychosocial work environment increased the risk of a new episode by more than twofold (odds ratio 2:15). The attributable fraction suggested that eliminating stress could prevent 53% of the cases. CONCLUSION: In a population of employees with no reported sleeping problems, 14.3% developed a sleeping problem during the coming year. Even when controlling for possible confounders, stress in the form of a 'poor' psychosocial work environment doubled the risk of developing a sleep problem.
Adult↗
Fear-avoidance beliefs and catastrophizing: occurrence and risk factor in back pain and ADL in the general population.
Fear-avoidance beliefs and catastrophizing have been shown to be powerful cognitions in the process of developing chronic pain problems and there is a need for increased knowledge in early stages of pain. The objectives of this study were therefore, firstly, to examine the occurrence of fear-avoidance beliefs and catastrophizing in groups with different degrees of non-chronic spinal pain in a general population, and secondly to assess if fear-avoidance beliefs and catastrophizing were related to current ratings of pain and activities of daily living (ADL). The study was a part of a population based back pain project and the study sample consisted of 917 men and women, 35-45 years old, either pain-free or with non-chronic spinal pain. The results showed that fear-avoidance beliefs as well as catastrophizing occur in this general population of non-patients. The levels were moderate and in catastrophizing a 'dose-response' pattern was seen, such that more the catastrophizing was, the more was pain. The study showed two relationships, which were between fear-avoidance and ADL as well as between catastrophizing and pain intensity. Logistic regression analyses were performed with 95% confidence intervals and the odds ratio for fear-avoidance beliefs and ADL was 2.5 and for catastrophizing and pain 1.8, both with confidence interval above unity. The results suggest that fear-avoidance beliefs and catastrophizing may play an active part in the transition from acute to chronic pain and clinical implications include screening and early intervention.
Activities of Daily Living↗
Identification of obstacles for chronic pain patients to return to work: evaluation of a questionnaire.
The Obstacles to Return-to-Work Questionnaire (ORQ) was developed and evaluated. A total of 154 patients with chronic musculoskeletal pain and prolonged work disability participated in the study. Factor analyses reduced the ORQ to 55 items grouped into 9 subscales. The subscales were named "Depression," "Pain intensity," "Difficulties at work return," "Physical workload and harmfulness," "Social support at work," "Worry due to sick leave," "Work satisfaction," "Family situation and support," and "Perceived prognosis of work return." The subscales showed satisfactory reliability. In order to determine predictive validity a discriminant analysis was conducted with sick leave 9 months after assessment as the outcome. This analysis indicated that the scales "Perceived prognosis of work return," "Social support at work," "Physical workload and harmfulness," "Depression," and "Pain intensity" could significantly predict sick leave and correctly classified 79% of the patients. The Multidimensional Pain Inventory and the Disability Rating Index could also significantly predict sick leave in this sample and correctly classified as many patients as the ORQ. However, these questionnaires do not include any work-oriented items and they had a lower specificity than the ORQ. This study suggests that patients' perceptions and beliefs about work and returning to work may be a significant hindrance for actual recovery.
Back Pain↗
The back pain beliefs of health care providers: are we fear-avoidant?
The purpose of this study was to survey the level of fear-avoidance beliefs for practicing general practitioners and physical therapists and to relate this to self-reported practice behaviors for patients with back pain. To this end, 60 general practitioners and 71 physical therapists were recruited. These participants completed a questionnaire including 11 items slightly revised from instruments designed to assess fear-avoidance beliefs in patients, and four items about treatment practices. The results indicated that these health care practitioners on the average generally held beliefs that are consistent with the current evidence, but there were also indications that some practitioners held beliefs reflecting fear-avoidance. More than two-thirds reported that they would advise a patient to avoid painful movements, more than one-third believed a reduction in pain is a prerequisite for return-to-work, while more than 25% reported that they believe sick leave is a good treatment for back pain. These beliefs were found to be related to reported practice behavior. Those with high levels of fear-avoidance beliefs were compared to those with low levels. Those with high levels of fear-avoidance belief had an increased risk for believing sick leave to be a good treatment (RR = 2.0; 90%CI = 1.02-3.92), not providing good information about activities (RR = 1.7; 90%CI = 1.19-2.45), and being uncertain about identifying patients at risk for developing persistent pain problems (RR = 1.5; 90%CI = 1.00-2.27). It is concluded that some practitioners hold beliefs reflecting fear-avoidance and that these beliefs may influence treatment practice.
Attitude of Health Personnel↗