Evidence & Methods Psychosocial factors can impact outcomes following surgery. The authors assess fear of movement. In this prospective cohort study, the authors found that early postoperative fear of movement and depressive symptoms are associated with inferior outcomes at six months postoperative. Early identification and intervention may make a difference---assuming that the association is one of direct or indirect causation. —The EditorsThe fear-avoidance model of Vlaeyen et al. [1], based on the work of Lethem et al. [2], Philips [3], and Waddell et al. [4], provides clinicians with a cognitive-behavioral framework for understanding chronic pain syndromes. Robust evidence supports the fear-avoidance model in patients with various musculoskeletal conditions [5], such as back and neck pain [6], [7], osteoarthritis [8], and fibromyalgia [9]. The model suggests that after an injury there are two pathways based on the way acute pain is interpreted. Pain that is perceived as nonthreatening will lead to a return to normal activity, but pain that is perceived as threatening will promote anxiety and give rise to pain-related fear that persists beyond the expected healing time. This fear leads to avoidance behaviors and a “disuse” syndrome that is associated with deconditioning and depression, which subsequently perpetuates the pain process.
The fear-avoidance model offers a promising framework for the development of chronic postoperative pain and disability. Two studies have demonstrated a predictive relation between preoperative pain catastrophizing (ie, tendency to magnify pain sensations) and increased pain after knee arthroplasty surgery [10], [11]. In patients following lumbar disc surgery, Johansson et al. [12] and den Boer and colleagues [13], [14] found that preoperative fear of movement was the best predictor of low quality of life (QOL) at 12-month follow-up and increased pain and disability at 6-month follow-up, respectively. Mannion et al. [15] reported that preoperative fear-avoidance beliefs about work, but not activity, was a significant predictor of disability 6 months after surgery in a variety of spinal disorders.
Limited research has examined the fear-avoidance model in patients undergoing spinal surgery for degenerative conditions. Abbott et al. [16] reported significant correlations between preoperative fear of movement and preoperative pain, disability, and QOL outcomes in patients after lumbar spine fusion. In our own work, a significant association was found between postoperative fear of movement and pain, disability, and physical health at 6 weeks and 3 months after laminectomy with or without arthrodesis [17].
Surgery rates for degenerative conditions have been rising steadily since the 1990s [18], [19], and fusion procedures account for almost half of the $1 billion spent annually by Medicare on spinal surgery [20]. Despite rapid increases in surgery rates, individuals after surgery for spinal degeneration continue to have poorer physical and mental functioning compared with the general United States population [21], [22]. More specifically, up to 40% report residual chronic pain and functional disability [23], [24], [25], [26]. Thus, the primary purpose of this study was 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. We hypothesized that both preoperative and early postoperative fear of movement would be a significant predictor of 6-month outcomes.
A total of 244 patients were referred to this study over a 21-month period by participating spine surgeons. Two hundred were eligible and 141 patients undergoing surgery for a lumbar (n=92) or cervical (n=49) degenerative condition were enrolled in the study after providing informed consent. Degenerative conditions included spinal stenosis, spondylosis with or without myelopathy, and spondylolisthesis. Patients who had surgery for spinal deformity as the primary indication, microsurgical
Of the 200 eligible patients approached, 141 (71%) agreed to participate in the study. There were no significant differences with regard to age, sex, race, insurance status, surgery type and area, and prior spinal surgery between eligible patients who were enrolled and those who were not enrolled. Of the 141 enrolled participants, 128 (91% follow-up) completed the 6-week and 120 (85% follow-up) completed the 6-month postoperative assessment. There were no significant differences between
The primary purpose of this study was to determine whether preoperative and early postoperative fear of movement predicted 6-month outcomes following surgery for degenerative conditions. Demonstration of this relation would inform clinical decisions regarding the need for screening and targeted treatment. Results partially supported our hypothesis for early postoperative, but not preoperative, fear of movement, which was found to be a risk factor for increased pain and disability and decreased
The findings from this study provide support for the fear-avoidance model in a postsurgical spine population. Early postoperative fear of movement, but not preoperative values, was predictive of increased pain intensity, pain interference, and disability, and decreased physical health at 6 months following surgery. Screening for fear of movement during the first postoperative clinic visit appears warranted to identify patients at risk for poor outcomes. Depressive symptoms in the preoperative
Over time, the chronic pain may confer an effect on these patients' psychological status. Studies have shown that a worse postoperative recovery after lumbar fusion is predicted when neuroticism, catastrophizing thoughts, kinesiophobia, mood alteration, or fear-avoidance beliefs are presented.37-40 We believed it necessary to account for these factors in our study.
The majority of studies have focused on preoperative psychosocial characteristics, including depression, anxiety, and fear-avoidance beliefs, which can be useful for surgical decision-making and hospital discharge planning [4–6]. However, studies have found that significant changes in psychosocial constructs such as fear of movement occur due to the surgical procedure [7–9]. Katz [10] suggests, that in some cases, early postoperative factors may be more strongly associated with chronic pain and disability after surgery than preoperative factors.
FDA device/drug status: Not applicable.
Author disclosures: KRA: Grant: Blaustein Fund (C, Paid directly to institution/employer); Grants: APTA (C, Paid directly to institution/employer), Foundation of Physical Therapy (D, Paid directly to institution/employer). CLS: Nothing to disclose. SLM: Nothing to disclose. LHR: Grant: Blaustein Fund (C, Paid directly to institution/employer). STW: Grant: Blaustein Fund (C, Paid directly to institution/employer).
The disclosure key can be found on the Table of Contents and at www.TheSpineJournalOnline.com.
This research was supported with funds from the Blaustein Pain Research Fund, the Blaustein Pain Treatment Center, Johns Hopkins Medicine.
