Original article
Longitudinal associations of kinematics and fear-avoidance beliefs with disability, work ability and pain intensity in persons with low back pain

https://doi.org/10.1016/j.msksp.2019.03.008Get rights and content

Highlights

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    Increased range-of-motion weakly associated with reduced disability in low back pain.

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    No association between spinal velocity and disability, work ability or pain.

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    Fear-avoidance belief is weakly related to velocity at start of a spinal flexion.

Abstract

Background

Impaired lumbar movement has cross-sectionally been associated with low back pain (LBP); however, the consequence of impaired movement on disability and pain in persons with LBP is poorly understood. Furthermore, fear-avoidance beliefs (FAB) may influence spinal movement, but the relation between fear-avoidance and kinematics is unclear.

Objectives

To investigate the longitudinal associations of kinematics and FAB with disability, work ability and pain in patients with LBP. Further, to explore associations between FAB and kinematics.

Design

Prospective observational study.

Method

Kinematic measures were performed on 44 persons with LBP at baseline, three and nine months. Motion sensors identified range-of-motion and velocity during a spinal flexion/extension. FAB, disability, work ability and pain were reported at all time points using questionnaires.

Results

Increased range-of-motion was weakly associated with less disability (−0.14 points, 95% CI -0.22 to −0.06). Velocity was not associated with disability, work ability or pain. Higher FAB of physical activity were associated with more disability (1.50 points, 95% CI 0.51 to 2.49) and pain (0.37 points, 95% CI 0.11 to 0.62). Higher work-related FAB was associated with lower work ability (−0.37 points, 95% CI -0.68 to −0.05). Moreover, higher FAB showed weak associations with lower velocity in the initial movement phase (−3.3°/s, 95% CI -6.1 to −0.5).

Conclusions

Of the kinematic measures, only range-of-motion was related to disability. Higher FAB was weakly associated with all self-reported outcomes and with lower velocity only at the initial flexion phase. However, the magnitude of these associations suggest marginal clinical importance.

Introduction

Altered lumbar kinematics and fear-avoidance beliefs have been associated with low back pain (LBP) (Laird et al., 2014; Wertli et al., 2014a). Measures of lumbar kinematics have been found to differentiate persons with and without LBP, for instance by reduced range-of-motion and reduced angular velocity in persons with LBP (Laird et al., 2014; Dieën et al., 2018; Laird et al., 2018). However, the consequences of altered lumbar kinematics on physical- and work related disability and on pain intensity over time among persons with LBP is not clear.

In addition to lumbar kinematics, fear-avoidance beliefs may negatively influence performance and function in persons with LBP (van Abbema et al., 2011; Vlaeyen and Linton, 2000), and are believed to influence the prognosis of LBP (Vlaeyen and Linton, 2000; Wertli et al., 2014b; Linton and Shaw, 2011). Thus, it is conceivable that fear-avoidance beliefs may influence lumbar kinematics. High pain-related fear has been associated with lower peak velocity of the lumbar spine in participants recently recovered from LBP (Thomas et al., 2008) although this is not found in participants with ongoing chronic LBP (Jette et al., 2016). It remains unclear if persons with more fear-avoidance beliefs have correspondingly reduced range-of-motion and velocity during spinal flexion over time. During a task specific movement, pain-related fear may manifest itself in different phases of the movement, e.g., in the initiation, intermediary or end phase of the movement. A cross sectional study reported that lower range-of-motion and velocity were associated with more anxiety, fear of movement and catastrophizing during the start phase of spinal movements in persons with chronic LBP (Vaisy et al., 2015). However, further studies are needed to understand how lumbar kinematics, fear-avoidance beliefs and self-reported outcomes relate to each other over time.

The aim of this study was therefore longitudinally to investigate if lumbar kinematic measures in segments of a standing flexion/extension movement and fear-avoidance beliefs are associated with disability, work ability and pain intensity within patients with LBP receiving physiotherapy treatment. We also examined within-person associations over time between fear-avoidance beliefs and lumbar kinematic measures.

Section snippets

Participants/study population

We performed a longitudinal, observational study of 44 patients with non-specific LBP receiving primary care physiotherapy in the period from May 2014 until March 2017. Eligible patients were invited to participate in the study when they first contacted the clinic seeking treatment for LBP. Kinematic measures and questionnaires were completed before the first consultation with the physiotherapist and at three and nine months follow-up. Inclusion criteria were current non-specific LBP of any

Results

Characteristics of the participants at baseline, and at three and nine months follow-up are reported in Table 1. Nine per cent of the participants were lost to follow-up at three months, and 32 per cent at nine months follow-up. Twenty-eight out of 44 included participants were female (64%), total mean age was 42.8 years (range 16–74) and 62% reported to have had pain >9 months.

Table 2 shows that range-of-motion increased from baseline to three months by 10.3° (95% CI 1.4 to 19.2) and from

Discussion

Of the kinematic measures, only larger range-of-motion during standing flexion/extension was longitudinally associated with reduced disability, albeit weakly. We found no associations between peak velocity and disability, work ability or pain intensity over time. Higher scores on the fear-avoidance subscale of physical activity were longitudinally associated with more severe disability and more pain, and higher scores on the subscale of work were associated with reduced work ability. Moreover,

Conclusion

Of the kinematic measures, only range-of-motion showed within-person longitudinal associations, albeit weakly, with self-reported disability. Higher fear-avoidance beliefs of physical activity was longitudinally associated with higher self-reported disability and pain, whereas higher fear-avoidance beliefs of work was longitudinally associated with lower work ability. Further, higher fear-avoidance beliefs of physical activity were weakly associated with lower peak velocity in the start phase

Conflicts of interest

None declared.

Ethical approval

The current study was approved by the Regional Committee for Ethics in Medical Research (project no. 2013/2244 REK Mid-Norway), and the participants provided written informed consent. The study was carried out according to the Declaration of Helsinki.

Funding

This work was supported by The Norwegian Fund for Post-Graduate Training in Physiotherapy and by grants from the Liaison Committee between the Central Norway Regional Health Authority and the Norwegian University of Science and Technology (NTNU).

Acknowledgements

The authors would like to thank the department of Physiotherapy in Trondheim Municipality for support and assistance during this project, the physiotherapists who contributed with recruitment of participants, and the participants who took part in the study.

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