The Role of Fear of Movement/ (Re) Injury in Pain Disability
The Role of Fear of Movement/ (Re) Injury in Pain Disability
The Role of Fear of Movement/ (Re) Injury in Pain Disability
4, 1995
It is now well established that in chronic low back pain, there is no direct relationship
between impairments, pain, and disability. From a cognitive-behavioral perspective,
pain disability is not only influenced by the organic pathology, but also by
cognitive-perceptual, psychophysiological, and motoric-environmental factors. This
paper focuses on the role of specific beliefs that are associated with avoidance of
activities. These beliefs are related to fear of movement and physical activity, which is
(wrongfully) assumed to cause (re)injury. Two studies are presented, of which the first
examines the factor structure of the Tampa Scale for Kinesiophobia (TSK), a recently
developed questionnaire that is aimed at quantifying fear of movement/(re)injury. In
the second study, the value of fear of movement/(re)injury in predicting disability levels
is analyzed, when the biomedical status of the patient and current pain intensity levels
are controlled for. In addition, the determinants of fear of movement/(re)injury are
examined. The discussion focuses on the clinical relevance of the fear-avoidance model
in relation to risk assessment, assessment of functional capacity, and secondary
prevention.
KEY WORDS: chronic low back pain; fear-avoidance; fear of movement; fear of (re)injury; fear of pain;
kinesiophobia; behavioral assessment.
INTRODUC~ON
Many people suffer from low back pain in the course of their lives, of which
not all seek health care. In the majority of the patients who seek care and refrain
from work, the pain problem resides within a few weeks. Data presented by the
Quebec Task Force on Spinal Disorders (1) show that 74% of the group of patients
1Institute for Rehabilitation Research, Zandbergsweg 111, 6432 CC Hoensbroek, The Netherlands.
2Department of Medical Psychology, University of Limburg, PO Box 616, 6400 MD Maastricht, The
Netherlands.
3Lucas Foundation for Rehabilitation, Zandbergsweg 111, 6432 CC Hoensbroek, The Netherlands.
4Correspondence should be directed to Dr. Johan W. S. Vlaeyen, Institute for Rehabilitation Research,
P.O. Box 192, 6430 AD Hoensbroek, The Netherlands.
235
1053-0487/95/1200-0235507.50/0 9 1995 Plenum Publishing Corporation
236
17 %
t
I
7da~m
4wko
7wks
13 %
I /'
12wks
8 %
1
24wks
Fig. 1. The natural history of chronic back pain. Percentage of sick leave in relation to pain
duration since onset (based on Spitzer et al., 1987).
with acute back pain resume their work within the period of 4 weeks after the
acute pain onset (Fig. 1). If a worker has not returned to work by 7 weeks, there
is a 50% probability that he/she will be off work at 6 months. About 8% of the
patients still is sick leaving 6 months after the acute pain onset. Similar findings
have been reported by Crook and Moldofsky (2): If a worker has not returned to
work by 3 months, there is a 50% probability that he/she will be off work at 15
months. The relatively small group of chronic back pain patients is responsible
for enormous health care and societal costs (75-90% of the costs) of back problems (3). What are the reasons for this group to become chronic pain sufferers?
One of possibilities would be that this group has more serious impairments than
the group of workers who resume their work earlier. However, there are no research reports that support this assumption. On the contrary, numerous studies
have shown that there is no perfect relationship between impairments, pain and
disability and suggest that the behavioral or biopsychosocial approach offers the
foundations for a better insight in how pain can become a persistent problem (48). The main assumption is that pain and pain disability are not only influenced
by organic pathology, if found, but also by psychological and social factors. For
example, from a biomedical view, return to work should only be encouraged when
the underlying pathology has healed. Otherwise, the risks of reinjury and repeated
failures would increase, subsequently leading to the promotion of chronicity. From
this biomedical perspective, staying off too long would be much safer than resuming work activities too early. Results reported by Crook and Moldofsky (2), however, are in support of the conjecture that early return to work contributes to a
decrease in work disability in musculoskeletal pain patients. The arguments include
the recognition that musculoskeletal incidents are enhanced by the immediate consequences such as diminished pain, increased attention from others, avoidance of
unpleasant and fearful situations, and the stabilization of the sick role. Moreover,
longstanding avoidance leads to disuse of the musculature which in turn augments
the deficits in the necessary motoric, social and vocational skills. In other words,
the pain disability is subject to a graded shift from structural/mechanical to cognitive/environmental control. Studies by Deyo et al. (9), Philips and Grant (10),
and Klenerman et al. (11) suggest that this shift occurs quite rapidly, probably
within the period of 4-8 weeks after the acute pain onset.
237
From a behavioral perspective (chronic) pain can best be studied as a hypothetical construct, which is not observable in itself but which can be inferred only
by its effects at some observable level. Three observable levels or response systems
of pain have been described repeatedly: psycho-physiological reactivity, the cognitive-perceptual system, and the overt motoric system (12).
Psycho-Physiological Reactivity
Cognitive-Perceptual Factors
Cognitive-perceptual responses refer to the way the patient perceives and interprets his/her environment, and the extent to which he/she thinks that control
can being excerted over the situation. One of the possible attributions is that pain
is a sign of a serious health problem, and has been referred to as "illness (or disease) conviction" (15). Such an appraisal may be based on a misinterpretation of
proprioceptive signals (16). A common appraisal reported by chronic pain patients
is "Catastrophizing," referring to an attentional bias toward negative aspects and
exaggeration of their situation. Catastrophizing is known to be associated with increasing distress, which in turn can increase pain by reducing pain tolerance levels
and by triggering unnecessary sympathetic arousal (17).
238
Avoidance Learning
In 1982, Fordyce et al. (5) described how pain behavior may result from avoidance learning. Avoidance refers to "the performance of a behavior which postpones
or averts the presentation of an aversive event" (18). Avoidance learning has long
been considered to underly the formation of many so-called "neurotic" symptoms
(19). In the case of pain, a patient may no longer perform certain activities because
he/she anticipates that these activities increase pain and suffering.
In the acute phase, avoidance behaviors such as resting, limping, or the use
of supportive equipment are effective in reducing suffering from nociception. Later
on, these protective pain and illness behaviors may persist in anticipation of pain,
instead of as a response to it. Longlasting avoidance of motoric activities can have
detrimental consequences, both physically (loss of mobility, muscle strength, and
fitness, possibly resulting in the "disuse syndrome") (20) and psychologically (loss
of self-esteem, deprivation of reinforcers, depression, somatic preoccupation).
Philips and Jahanshahi (21) found that, in a group of headache sufferers, avoidance
was the most prominent behavior reported by these individuals. In their study,
avoidance was not limited to avoidance of movement, but also withdrawal from
social situations. Philips (22) argued in favor of a cognitive theory of avoidance
behavior, rather than the operant theory. She takes the view that avoidance is influenced by the expectancy that further exposure to certain stimuli will promote
pain and suffering. This expectancy is assumed to be based on previous aversive
experiences with the same or similar situations. She also pointed to the similarities
between avoidance behavior displayed by pain patients and that of patients with
excessive fears and phobias, and suggests that "chronic pain and chronic fear--both
aversive experiences which result in avoidance behavior--may share important characteristics" (22, p. 277). Recent studies have focused on the relationship between
fear/anxiety and chronic pain, of which the object of fear has been fear of pain
(23-25), fear of work-related activities (26), and fear of movement that is assumed to
cause (re)injury (27-29).
Fear of Pain
239
physiologic, and motoric aspects of fear of pain. The authors found correlations
with measures of anxiety, cognitive errors, depression, and disability. In a second
study (25), the authors showed that, in a group of chronic low-back pain patients,
greater pain-related anxiety was associated with higher predictions of pain and less
range of motion during a procedure involving a passive but painful straight leg
raising test. They also showed that different types of pain-anxiety symptoms have
different relations with pain coping responses as measured with the Coping Strategies Questionnaire (CSQ; 31). Cognitive anxiety responses (e.g., "I find it hard to
concentrate when I hurt") negatively interfered with coping strategy use, whereas
physiological anxiety responses appeared to enhance coping (32).
McCracken and Gross (25) also found a substantial overlap between the CSQfactor "Catastrophizing" and anxiety symptoms. This is of interest as previous studies found strong correlations between catastrophizing attributions and depression.
Fear of Work-Related Activities
CLBP patients may not only fear pain, but also activities that are expected
to cause pain. In this case, fear is hypothesized to generalize to other situations
that are closely linked to the feared stimulus. Vlaeyen (33) found that a group of
50 CLBP patients had mean elevated scores that were clinically significant on the
"social phobia" and "agoraphobia" scales of the Fear Survey Schedule (FSS-III;
34, 35). More specifically, Waddell et al. (26) developed the Fear-Avoidance Beliefs
Questionnaire (FABQ), focusing on the patient's beliefs about how work and physical activity affect his/her low back pain. The FABQ consists of two scales, fearavoidance beliefs of physical activity, and fear-avoidance beliefs of work, of which
the latter was consistently the stronger in predicting work disability. The authors
found that fear-avoidance beliefs about work are strongly related with disability of
daily living and work lost in the past year, and more so than biomedical variables
such as anatomical pattern of pain, time pattern, and severity of pain.
Fear of Movement/(Re)Injury
A more specific kind of fear-avoidance concerns fear of movement and physical activity that is (wrongfully) assumed to cause (re)injury. In accordance with
Lethem et al. (23), Crombez (29) empirically derived a subgroup of 'Avoiders" and
"Confronters" among a sample of CLBP patients using self-report. Although there
were no differences found in gender, age, number of back surgeries, use of medication, and reported pain intensity, "avoiders" reported a higher frequency of pain,
pain of longer duration, more fear of pain, more fear of injury, and more attention
to back sensations than the confronters. When exposed to a maximal performance
test with minimal back muscle involvement (flexion and extension of the knee),
confronters showed a significantly better performance than the avoiders. Regression
analyses revealed that when variance due to gender, age, and body weight was cor-
240
rected for, behavioral performance was significantly predicted by both reported fear
of pain and reported fear of injury.
Kori et al. (27) introduced the term "kinesiophobia" (kinesis = movement)
for the condition in which a patient has "an excessive, irrational, and debilitating fear
Subjects
One hundred and twenty-nine CLBP patients that were admitted to the
Hoensbroek Rehabilitation Center for an inpatient behavioral rehabilitation program were included in this study. The sample consisted of 50 men and 79 women
with a mean age of 40.1 years (SD = 9.0). The duration of pain complaints was
9.9 years (SD = 8.8). Of the total sample, 63.9% received financial disability compensation for at least 1 year, with a mean duration of 3.7 years (SD = 4.7), 38%
had received one or more back surgeries, and 24.8% used supportive equipment
for ambulation. All patients had minimal organic findings or displayed pain complaints that were disproportionate to the demonstrable organic basis of their pain.
241
Measures
Pain Intensity. The Pain Rating Index (PRI-total) score of the Dutch version
of the McGill Pain Questionnaire (MPQ-DV; 37, 38) a widely used measure of
pain experience, is used in this study.
Pain Cognitions. The Pain Cognition List (PCL-e; 39) is a 77-item questionnaire aimed at the assessment of distorted pain cognitions and experienced selfcontrol. Five scales are factor-analytically derived: Pain Impact, Catastrophizing,
Outcome-Efficacy, Acquiescence, and Reliance on Health care. For this study only
the subscales Pain impact and Catastrophizing were selected. "Pain impact" reflects
the extent to which the pain interferes with daily activities. "Catastrophizing" refers
to an attentional focus on negative aspects of the patient's situation.
Fear of Movement/(Re)Injury. A Dutch version of the Tampa Scale for Kinesiophobia (27, 36) is a questionnaire that is aimed at the assessment of fear of
(re)injury due to movement. The original 17-item TSK was translated into Dutch
(TSK-DV) by the authors and subsequently corrected by a professional translater.
The same scoring format and keys were maintained. Each item is provided with a
4-point Likert scale with scoring alternatives ranging from "strongly disagree" to
"strongly agree." A total score is calculated after inversion of the individual scores
of items 4, 8, 12, and 16. Based on the data of the current patient sample, following
information underscores the reliability of the TSK-DV. According to the Kolmogorov-Smirnov goodness-of-fit test, the scores on the TSK were normally distributed
(K-S, z = .820, p = 0.512). Cronbach's alpha was 0.77, which is fair. These data
are consistent with an earlier study using a different chronic pain sample (28).
Fear. The Dutch version of the Fear Survey Schedule (FSS-III-R; 34, 35) is
used. The FSS-III-R is a 76-item questionnaire consisting of clusters of phobic complaints: Social Phobia, Agoraphobia, Fear of Bodily Injury, Illness and Death, Fear
of Sex and Aggression, and Fear of Living Organisms. For this study only the cluster
fear of Bodily Injury, Illness, and Death is selected.
Pain Control The Pain Control scale of a Dutch version of the Coping Strategies Questionnaire (31), developed by Spinhoven and Linssen (40) was selected for
this study.
Procedures
242
Component
Alpha rTSK.TOTLabel
.71
.72*
TSK-H: Harm
I wouldn't have this much pain if there weren't something
11.
potentially dangerous going on in my body.
3.
My body is telling me I have something dangerously wrong.
6.
My accident has put my body at risk for the rest of my life.
II
.63
.56*
Ill
.53
.38*
IV
.61
.57*
Results
243
TSK-harm
TSK-fear of (re)injury
TSK-exercise
TSK-F
TSK-E
TSK-A
-.23
.30
-.15
.21
-.31
.02
Table IlL Correlations Among TSK Subscales and Pain Impact (PCL-e), Catastrophizing (PCL-e),
Outcome-Efficacy (PCL-e), Acquiescence (PCL-e), Reliance on Health Care (PCLoe), Pain Control
(CSQ), Pain Intensity (MPQ), and Fear of Bodily Injury, Illness and Death (FSS-III-R)
Pain impact
Catastrophizing
Pain intensity
Pain control
Fear of blood, injury
TSK-H
TSK-F
TSK-E
.23*
.47"*
.24*
.02
.32**
.38**
.52"*
.25*
.09
.37**
.01
.06
.11
-.03
-.15
TSK-A
.13
.35**
.16
-.16
.14
TSK-TOT
.27*
.54**
.21"
-.10
.32**
*p < .01.
**p < .001 (one-tailed).
correlations are found between Pain Control and any TSK subscale, which suggests
that the T S K taps a particular aspect of beliefs that is more related to the interpretation, attribution or appraisal of the situation, rather than to expectancies about
self-efficacy and pain control. Despite the four-factor solution, arguments can be
formultated in favor of the use of the TSK total score, rather than the factors.
These are: the relatively high intercorrelations among some of the factors, the more
favorable internal consistency of the total score, and the good construct validity of
the total score as displayed by the pattern of correlations with concurrent measures.
Method
Subjects
Thirty-three chronic low back pain patients who were on a waiting list for a
behavioral rehabilitation program agreed to participate in the experiment. The
244
group consisted of 17 female and 16 male patients with a mean age of 37.4 years
(SD = 9.2, range = 22-53).
The mean duration of their pain complaints was 7.6 years (SD --- 8.2; range
= 0.7-29). As is study 1, all patients had minimal demonstrable organic findings.
Measures
Level of Impairment. The Medical Evaluation and Diagnostic Information
Coding system (MEDICS; 41) was used by a rehabilitation physician to quantify
the biomedical signs and symptoms that may be related to the patients' reports of
pain. MEDICS was completed after examination of the medical chart of the patient.
For this study, the total pathology score using the medical concensus weights reported by Rudy et al. (41) is used.
Pain Intensity. The Visual Analog Scale (VAS; 42), a widely used measure of
pain experience, is used in this study. Patients were asked to rate the mean pain
intensity over the last week. A 10 centimeter line was provided with written anchors
at the two extremes: "no pain at all" and "the worst pain ever experienced."
Pain Cognitions. For this study, the subscale Catastrophizing of the Pain Cognition List (PCL-e; 39) is selected.
Fear. A Dutch version of the Tampa Scale for Kinesiophobia (TSK-DV; 36) is
a questionnaire that is used for the assessment of fear of (re)injury due to movement.
Level of Disability. One of the best developed self-report measures of disability
in activities of daily living, the Roland Disability Questionnaire (RDQ; 43) is used
in this study.
Procedure
When entering the laboratory, all patients were given brief information about
the experiment. Subsequently they were requested to complete the questionnaires.
Then the subjects were asked to perform seven activities that were part of another
study examining the influence of prior expectations on behavioral performance (44).
The experiment ended with the completion of a number of questions regarding
their performance, and their beliefs about fear of movement/(re)injury.
Statistics
245
duration and gender were entered into the equation first, to test whether one of
the other independent variables (Medics, Pain intensity, Catastrophizing) would
contribute significantly to the variance in the dependent variable after controlling
for these socio-demographic variables.
Results
Question 1
As displayed in Table IV, RDQ correlates significantly only with TSK-DV. Correlations with gender and compensation status were low (r= -.17 and .13, respectively). The only significant differences between the high and low disability subjects
was on TSK-DV and Catastrophizing (Table V). Consequently, Table VI shows that
among the variables entered in the regression model, fear of movement/(re)injury
is the best predictor of pain disability as measured by the RDQ. Of interest is that
catastrophizing, which is predictive for fear, does not directly predict pain disability.
However, the percentage of explained variance is rather modest (13%). On the
other hand, pain intensity and biomedical findings were not predictive of pain disability.
Table IV. Means, SD for Age, Duration of Pain (Years), Current Pain Intensity (VAS),
Age (years)
Pain duration (years)
Pain intensity (VAS)
Catastrophizing (PCL-e)
Impairment (medics)
Fear of movement (TSK-DV)
Pain disability (RDQ)
Mean
SD
37.4
7.6
51.6
48.2
-.70
40.4
13.8
9.2
8.2
22.2
13.1
.78
6.6
4.2
.03
-.33
.23
.29
.04
.49*
--
Table V. t-Tests for the Differences Between Low-Disabled Subjects (RDQ _< 15) and High-Disabled
High-disability subjects
(n = 18)
(n = 15)
Mean
Age (years)
Pain duration (years)
Pain intensity (VAS)
Catastrophizing (PCL-e)
Impairment (medics)
Fear of movement (TSK-DV)
Pain disability (RDQ)
36.7
7.4
45.4
44.1
-.59
38.1
10.7
SD
Mean
SD
9.5
7.0
20.7
14.3
.67
7.0
3.0
38.2
7.9
59.0
53.0
-.82
43.3
17.5
9.1
9.7
22.4
9.9
.88
4.9
1.4
NS
NS
NS
.050
NS
.022
.000
246
Table VI. Summary of Stepwise Hierarchical Regression Analysis of Pain Disability (RDQ), with
Pain Duration and Gender Entered in the First Step and Variables Fear of Movement/(Re)Injury
(TSK-TOT), Catastrophizing (PCL-e), Pain Intensity (VAS), and Biomedical Findings (MEDICS)
Tested with a Forward Inclusion Methoda
Ad'.ll
Step
Independent variables
R2
R2
Beta
1.
Pain duration
Gender
.04
.12
-.37
.07
2.
Pain duration
Gender
Fear of movement/(re)injury (TSK-TOT)
.17
.27
-.19
.12
.44*
"Dependent variable: Level of pain disability (RDQ). Variables not in the equation: pain intensity (VAS),
catastrophizing (PCL-e), biomedical findings (MEDICS).
*p _<0.05.
Table VII. t-Tests for the Differences Between Low-Fear Subjects (TSK-DV _<37) and High-Fear
Age (years)
Pain duration (years)
Pain intensity (VAS)
Catastrophizing (PCL-e)
Impairment (medics)
Fear of movement (TSK-DV)
Pain disability (RDQ)
Low-fear subjects
(n = 11)
Mean
SD
High-fear subjects
(n = 22)
Mean
SD
39.2
9.6
44.4
41.5
-.84
33.3
10.7
36.5
6.6
55.2
51.5
-.64
44.0
15.3
10.1
8.2
16.0
11.9
.55
3.4
3.8
8.9
8.2
24.3
12.6
.86
4.6
3.5
NS
NS
NS
.038
NS
.000
.002
Question 2
As displayed in Table IV, and consistent with previous findings, TSK-DV correlates significantly with catastrophizing and pain disability, and negatively with pain
duration. There was a modest correlation with gender (r=.20) but, in contrast to
previous findings (36), not with compensation status (r=.08). Differences between
high and low fearful subjects are found for measures of catastrophizing and pain
disability (Table VII). As shown in Table VIII, fear of movement/(re)injury can best
be predicted by catastrophizing, which accounted for an additional 17% of the variance, beyond the 15% prediction by gender and pain duration simultaneously. Pain
intensity and biomedical findings did not add any predictive value to the just-mentioned variables.
DISCUSSION
247
Table
md'.ll
Step Independentvariables
Rg
R2
Beta
1.
Painduration
Gender
.15
.21
-.40
-.11
2.
Painduration
Gender
Catastrophizing (PCL-e)
.32
.40
-.28
-.19
.45*
increase pain is a spontaneous and adaptive reaction of the individual (45); it usually
allows the healing process to occur. In chronic pain patients, however, avoidance
behavior appears to persist beyond the expected healing time. One of the reasons
that avoidance behaviors persist is not only the short-term effects of reduced suffering, but also the influence of certain beliefs and expectations (22). If the individual believes that further exposure to certain stimuli will increase pain and
suffering, avoidance or escape will be likely to occur. So far, little scientific attention
has been drawn to the specific beliefs that are related to avoidance. In this article,
a particular belief is put forward that is hypothesized to enhance avoidance, namely
the expectation that movement can cause (re)injury, and thus increased suffering.
The first study shows that the TSK-DV is composed of four factors: Harm,
Fear of injury, Importance of exercise, and Avoidance, which are not totally independent. Based on both the intercorrelations among the four factors, the reliability
coefficients, and the validity data it can be concluded that the TSK-DV can be used
as a single factor as well. The second study revealed that fear of movement/(re)injury is the best predictor for self-reported disability levels, rather than biomedical
findings, pain intensity levels, and catastrophizing. The second finding was that
catastrophizing, rather than pain intensity ratings and biomedical findings is predictive of fear of movement/(re)injury. An unexpected finding is the negative correlation between fear of movement/(re)injury and pain duration, and would suggest
that this particular fear extinguishes with time, or that more chronically disabled
patients are less likely to acknowledge fear. Future studies need to clarify this issue.
Because of the relatively small sample size, the unexpected association may be coincidental as well.
Although positive correlations may not be confused with causal effects, both
findings underscore parts of a cognitive-behavioral model displayed in Fig. 2. This
model represents the mechanism how fear of movement/(re)injury possibly contributes to the maintenance of chronic pain disability in chronic low back pain, starting
with the injury occuring during the acute phase. The painful experiences, that are
intensified during movement, will elicit catastrophizing cognitions in some individuals and more adaptive cognitions in others.
248
249
injury
oilily,
I
Disuse
I
/Depre~l~ _~. _ l
Avoidance
PeJnfulexpedenoes
Recovery
l
ConfrontalJon
+\ / C,4~lTophlzlng
]Fig,2. Cognitive-behaviomodel
ral of fearof movement/(re)injury.
Fear of movement/(re)injury may also influence patterns of performance of
workers with low back pain in an occupational setting. Clinicians are often requested to make judgments about the present and future functional capacity of
patients on the basis of dynamometry. The assumption hereby is that lumbar (isokinetic) dynamometry provides objective and unbiased measures and that it can
quantify maximal functional capacity. Menard et al. (52), for example, found a difference in the pattern of dynamometry in two groups of low back pain patients
who differed only in the propensity of abnormal illness behavior (as indicated by
the Waddell score), and proposed that fear of pain of movement might be one of
the possible explanations. The plausability of this explanation is corroborated by
earlier studies (29, 36) in which a relation between fear of movement/(re)injury
and behavioral performance is demonstrated. This means that a valid assessment
of functional capacity cannot be carried out without controlling for fear-avoidance
beliefs.
In occupational rehabilitation, early identification of catastrophizing and fear
of movement/(re)injury appears to be important in preventing chronic back disability. The TSK-DV has the potential to identify a subgroup of CLBP patients whose
disability is mainly determined by the specific fear of movement/(re)injury and not
by current pain intensity, the underlying organic pathology, or nocieeption. For this
subgroup, a specific treatment might be applied. Although cognitive-perceptual factors, and catastrophizing in particular, are associated with fear of movement, didactic lectures, education, or rational argument will not be as effective as more
behavioral forms of intervention. As Bandura (53) points out, symbolic evidence is
not nearly as credible as first-hand evidence. For a fearful patient, it is far more
convincing to actually see him/herself behaving differently than it is to be told that
he/she is capable of behaving differently. For individuals suffering from phobias,
graded exposure to the feared stimulus has proven to be a most effective treatment
(54). Consequently, for this CLBP subgroup, a more systematic application of
graded exposure to movement, such as described by Fordyce et al. (5) and Lind-
250
str6m et al. (55), is warranted. The movements that are chosen for such an exposure
can best be matched with the work-related activities that are needed to resume
the job responsibilities after the sick leave period. Randomized prospective research studies including cost-effectiveness analyses demonstrating the impact of
such a customized approach are likely to be promising, and badly needed. The
available knowledge gained both in the predictors of disability and in developing
behavioral rehabilitation programs should be applied to the field of secondary prevention (56). Waiting until pain problems have fully developed into chronic and
almost irreversable situations is ethically and economically unjustifiable.
ACKNOWLEDGMENTS
The authors wish to thank the staff of the department of Pain Rehabilitation
and Rheumatology of the Lucas Foundation for Rehabilitation, Hoensbroek, who
contributed considerably to the clinical management of the patients included in this
study. We also wish to acknowledge the assitance of Nienke Haga of the Rehabilitation Center "Blixembosch" at Eindhoven, Robert Miihlig of the De Wever Hospital at Heeden, and Huub Vonken and Wil Sillen of the outpatient clinic of the
Lucas Foundation for Rehabilitation for the referrals of patients that were included
in the second study. Thanks are also extended to Arnoud Arntz and Wip Bakx for
their advice at various stages of the study, and to Geert Crombez, Jolanda van
Haastregt, and an anonymous reviewer for their useful comments on an earlier
version of this article. This research was partly supported by Grant O G 91-088 of
the Dutch Insurance Council.
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