Early postoperative fear of movement predicts pain, disability, and physical health six months after spinal surgery for degenerative conditions.

BACKGROUND CONTEXT: The fear-avoidance model offers a promising framework for understanding the development of chronic postoperative pain and disability. However, limited research has examined this model in patients undergoing spinal surgery. PURPOSE: To determine whether preoperative and early postoperative fear of movement predicts pain, disability, and physical health at 6 months following spinal surgery for degenerative conditions, after controlling for depressive symptoms and other potential confounding variables. STUDY DESIGN/SETTING: A prospective cohort study conducted at an academic outpatient clinic. PATIENT SAMPLE: One hundred forty-one patients undergoing surgery for lumbar or cervical degenerative conditions. OUTCOME MEASURES: Self-reported pain and disability were measured with the Brief Pain Inventory and the Oswestry Disability Index/Neck Disability Index, respectively. The physical composite scale of the 12-Item Short-Form Health Survey (SF-12) measured physical health. METHODS: Data collection occurred preoperatively and at 6 weeks and 6 months following surgery. Fear of movement was measured with the Tampa Scale for Kinesiophobia and depression with the Prime-MD PHQ-9. RESULTS: One hundred and twenty patients (85% follow-up) completed the 6-month postoperative assessment. Multivariable mixed-method linear regression analyses found that early postoperative fear of movement (6 weeks) predicted pain intensity, pain interference, disability, and physical health at 6-month follow-up (p<.05). Preoperative and early postoperative depression predicted pain interference, disability, and physical health. CONCLUSION: Results provide support for the fear-avoidance model in a postsurgical spine population. Early postoperative screening for fear of movement and depressive symptoms that do not acutely improve following surgical intervention appears warranted. Cognitive and behavioral strategies may be beneficial for postsurgical patients with high fear of movement and/or depressive symptoms.

Cognitive-behavioral-based physical therapy to improve surgical spine outcomes: a case series.

BACKGROUND AND PURPOSE: Fear of movement is a risk factor for poor postoperative outcomes in patients following spine surgery. The purposes of this case series were: (1) to describe the effects of a cognitive-behavioral-based physical therapy (CBPT) intervention in patients with high fear of movement following lumbar spine surgery and (2) to assess the feasibility of physical therapists delivering cognitive-behavioral techniques over the telephone. CASE DESCRIPTION: Eight patients who underwent surgery for a lumbar degenerative condition completed the 6-session CBPT intervention. The intervention included empirically supported behavioral self-management, problem solving, and cognitive restructuring and relaxation strategies and was conducted in person and then weekly over the phone. Patient-reported outcomes of pain and disability were assessed at baseline (6 weeks after surgery), postintervention (3 months after surgery), and at follow-up (6 months after surgery). Performance-based outcomes were tested at baseline and postintervention. The outcome measures were the Brief Pain Inventory, Oswestry Disability Index, 5-Chair Stand Test, and 10-Meter Walk Test. OUTCOMES: Seven of the patients demonstrated a clinically significant reduction in pain, and all 8 of the patients had a clinically significant reduction in disability at 6-month follow-up. Improvement on the performance-based tests also was noted postintervention, with 5 patients demonstrating clinically meaningful change on the 10-Meter Walk Test. DISCUSSION: The findings suggest that physical therapists can feasibly implement cognitive-behavioral skills over the telephone and may positively affect outcomes after spine surgery. However, a randomized clinical trial is needed to confirm the results of this case series and the efficacy of the CBPT intervention. Clinical implications include broadening the availability of well-accepted cognitive-behavioral strategies by expanding implementation to physical therapists and through a telephone delivery model.

Comparative study of short forms of the Tampa Scale for Kinesiophobia: fear of movement in a surgical spine population.

OBJECTIVE: To compare the factor structure of 6 short forms of the Tampa Scale for Kinesiophobia (TSK) by means of confirmatory factor analysis in patients after spinal surgery for degenerative conditions. DESIGN: A cross-sectional survey study. SETTING: University-based surgical clinic. PARTICIPANTS: Adults (N=137) treated by spinal surgery for a degenerative condition (ie, spinal stenosis, spondylosis with or without myelopathy, and spondylolisthesis). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Patients completed the TSK within 3 months of hospital discharge. RESULTS: Confirmatory factor analysis demonstrated that the 2-factor models of the TSK-13 and TSK-11 had a reasonable fit for the data, with internal consistency values >.70. A 1-factor TSK-4 (items 3, 6, 7, and 11) demonstrated an excellent fit for the data, but an adequate internal consistency was not maintained. A poor fit was noted for the 1-factor models of the TSK-13 and TSK-11, and a 4-item TSK (items 1, 2, 9, and 11). CONCLUSIONS: The current study provides further evidence that specific short-form versions of the TSK may be useful for assessing fear of movement in surgical populations. Results support the measurement of fear of movement using the 2-factor, 13- and 11-item versions of the TSK in patients after spinal surgery. A TSK-4 (items 3, 6, 7, and 11) offers a promising alternative to the TSK-13 and TSK-11. However, further research is needed to test the validity and reliability of the TSK-4 in patients undergoing spinal surgery in order to support its use in a clinical environment. Researchers and clinicians interested in a shorter measure of fear of movement should consider using the TSK-11.

Examining the role of positive and negative affect in recovery from spine surgery.

Consistent evidence supports a significant association between lower positive affect and higher negative affect and increased pain and disability in adults with chronic pain. However, examining this relation in surgical populations has received little empirical consideration. The primary purpose of this study was to determine whether preoperative and postoperative positive and negative affect predict pain, disability, and functional status after spine surgery. A secondary objective was to assess the relation of depression to postoperative outcomes compared with positive and negative affect. Participants were 141 patients treated by spine surgery for lumbar or cervical degeneration. Data collection occurred at baseline and 6 weeks and 3 months postoperatively. Affect was measured with the Positive and Negative Affect Schedule. Multivariable mixed-model linear regression analyses found that preoperative variables were not predictive of postoperative pain, disability and functional status. However, multivariable postoperative analysis found that 6-week positive affect predicted functional status, and 6-week negative affect predicted pain interference and pain-related disability at 3 months following surgery. Postoperative depression demonstrated statistically significant and stronger associations with pain intensity, pain interference, and pain-related disability at 3-month follow-up, as compared with negative affect. Results suggest that positive affect and depression are important variables to target when seeking to improve postoperative outcomes in a spine surgery population. Recommendations include postoperative screening for positive affect and depression, and treating depression as well as focusing on rehabilitation strategies to bolster positive affect so as to improve functional outcomes after spine surgery.

The effect of fear of movement beliefs on pain and disability after surgery for lumbar and cervical degenerative conditions.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: To examine differences between preoperative and postoperative fear of movement and investigate the relationship between fear of movement and pain, disability and physical health after spinal surgery for degenerative conditions. SUMMARY OF BACKGROUND DATA: Consistent evidence supports the relationship between fear of movement and higher levels of pain and disability in various chronic pain populations. Fear of movement among patients undergoing spinal surgery for chronic pain has received little attention in the literature. METHODS: Participants were 141 patients treated with surgery for lumbar and cervical degenerative conditions. Assessments were conducted before surgery and 6 weeks and 3 months after hospitalization. Fear of movement was measured with the Tampa Scale for Kinesiophobia and outcomes were measured with the Brief Pain Inventory, Oswestry or Neck Disability Index, and 12-Item Short Form Health Survey (SF-12). RESULTS: Follow-up rates were 91% and 87% for 6 weeks and 3 months, respectively. Fear of movement beliefs improved after surgery, but 49% of patients continued to have high fear of movement at 6-week follow-up and 39% at 3-month follow-up. Patients with higher levels of fear of movement had poorer postoperative outcomes. Multilevel linear regression analyses found that postoperative fear of movement was independently associated with postoperative pain intensity, pain interference, disability, and physical health (P < 0.001), after controlling for depression, age, sex, education, race, comorbidities, type and area of surgery, prior surgeries, and baseline outcome score. Preoperative fear of movement was not predictive of poorer surgical outcomes. CONCLUSION: Results demonstrate that postoperative but not preoperative fear of movement beliefs explain unique and significant variance in postoperative pain, disability, and physical health. Clinicians interested in improving surgical outcomes should address postoperative fear of movement along with other traditional clinical and medical risk factors. Recommendations include postoperative screening for high fear of movement beliefs and incorporating cognitive-behavioral techniques into postoperative rehabilitation for at-risk surgical spine patients.

Confirmatory factor analysis of the Short Form McGill Pain Questionnaire with burn patients.

The Short Form McGill Pain Questionnaire (SF-MPQ) is an abbreviated version of McGill Pain Questionnaire (MPQ) developed for pragmatic reasons to improve the clinical utility of the MPQ. Although the SF-MPQ has been used in more than 250 published studies, few studies have examined the core constructs it measures. The objective of this study was to evaluate in a sample with burn injuries whether the factor structure of the SF-MPQ is consistent with the theoretic pain constructs it purports to measure. Participants (n = 338) met American Burn Association's criteria for major burn injury and had a mean total body surface area burned of 14%. They were mostly male (70.1%) and Caucasian (63.4%) with an average age of 41.25 years. There were 2 primary findings. First, confirmatory factor analysis yielded fit index values demonstrating viability of a 2-factor, oblique, solution composed of sensory and affective latent constructs. These findings were consistent with previous work and the theoretic constructs. Second, results from a relatively new model consisting of 8 SF-MPQ items demonstrated potential viability for measuring similar constructs.