Elsevier

Pain Management Nursing

Volume 15, Issue 3, September 2014, Pages 593-602
Pain Management Nursing

Original Article
Self-Efficacy and Fear Avoidance Beliefs in Chronic Low Back Pain Patients: Coexistence and Associated Factors

https://doi.org/10.1016/j.pmn.2013.04.004Get rights and content

Abstract

A cross sectional study was conducted with the objective to assess the coexistence of self-efficacy and fear avoidance beliefs and establish the associated factors. Data collection was performed (215 individuals with lower back pain at three health services and two industries). The following instruments were used: Tampa Scale for Kinesiophobia, Beck's Depression Inventory, Piper's Fatigue Scale, Oswestry Disability Index, and the Chronic Pain Self-Efficacy Scale. Wilks' lambda test was performed, followed by MANOVA model to assess the effect of self-efficacy beliefs and fear avoidance on independent variables. Most subjects were women (65.1%), 45 years of age or younger (50.7%), with a family income between $450 and $1,350 per month (49.3%). Depression was present in 21.4%, fatigue in 29.3%, and disability in 68%. The average (standard deviation) of self-efficacy was 180.8 (60.4), and fear avoidance was 42.0 (11.5). A significant negative correlation was observed between the total score of both beliefs. The Wilks' lambda test showed that gender, income, depression, disability, and fatigue were significant and were included in the model. In the Manova analysis, low self-efficacy was associated with lower income, fatigue, depression, and level of disability (p < .001). High fear avoidance was associated to the male gender, lower income, depression, and level of disability (p < .001). The analysis of the confidence areas showed that a reduced self-efficacy and increased fear avoidance are related to an increased level of disability (p < .001). Specific intervention strategies must be implemented change these beliefs.

Introduction

Low back pain is a public health problem with elevated societal costs. This problem affects approximately 20% of the population worldwide (Català et al., 2002; Hardt, Jacobsen, Goldberg, Nickel, & Buchwald, 2008; Wong & Fielding, 2011) and approximately 30% of the population in Brazil (Dellaroza, Pimenta, & Matsuo, 2007; Sá, Baptista, Matos, & Lessa, 2009). Seventy-five percent of patients with low back pain present the same complaints after a 1-year follow-up assessment, and 30% of patients develop disabilities related to work and daily activities as well as symptoms of anxiety and depression (Lamb et al., 2007).

Patients with chronic pain frequently present dysfunctional beliefs, attitudes, and behaviors, most likely resulting from the experience of acute pain. Studies have shown that some patients with low back pain believe that physical activity aggravates the discomfort, that emotions are not related to the pain, that pain always results in disability, that they deserve special attention due to their pain, and that the only acceptable outcome for their situation is the elimination of pain (Pimenta, 1999; Pimenta, 2001; Pimenta & Cruz, 2006).

These dysfunctional beliefs concerning low back pain are erroneous conceptions that contribute to increased pain intensity and disability (Vandeenberghe, 2005). Of the beliefs described as most important to low back pain, self-efficacy and fear avoidance of pain or movement stand out.

Self-efficacy is the belief in one's ability to successfully perform specific tasks or behaviors to produce a desirable outcome. When self-efficacy is low, pain and fear avoidance behaviors increase (Salvetti & Pimenta, 2007).

The fear avoidance belief model suggests that patients fear movement because of the resulting pain, fear of aggravating their condition, or fear of causing a new problem. This fear can lead to two coping responses: confrontation or avoidance (de Jong et al., 2005). Confrontation is an adaptive response that allows an individual to perform the movement, which reduces fear as well as increases activity and functioning. Avoidance is a maladaptive response that leads the individual to avoid movement, which decreases activity and functioning as well as contributes to the persistence of pain (Woby, Urmston, & Watson, 2007).

The values, attitudes, beliefs, expectations, and judgments of the patient concerning their pain, capacity to cope, and therapeutic options influence the experience of pain and the treatment outcomes. In other words, cognitive factors can exacerbate pain and suffering, contributes to disability, and influence responses to therapy (Pimenta & Cruz, 2006).

A cross-sectional study of Brazilian patients with chronic low back pain found that self-efficacy beliefs and the fear avoidance of pain were independently associated with disability. Patients with low self-efficacy were two times more likely to have a risk of disability, and high fear avoidance of pain increased the risk of disability by 41% compared with patients who were low in fear. In addition, these beliefs are considered essential in the study of chronic pain; furthermore, correlations exists among other beliefs related to emotion, solicitude, medical cures, and physical damage (Salvetti, Pimenta, Braga & Correa, 2013).

Previous studies have identified factors associated with self-efficacy and fear avoidance beliefs (Costa, Maher, McAuley, Hancock, & Smeets, 2011; Denison, Asenlöf, Sandborgh, & Lindberg, 2007; Woby et al., 2007); however, none have analyzed the factors associated with both beliefs simultaneously. Understanding these factors is essential to propose interventions that seek to improve the physical and psychological functioning of individuals with low back pain. Thus, the present study seeks to fill the gap in the literature by evaluating the prevalence of self-efficacy and fear avoidance beliefs among patients with low back pain, thereby verifying the correlation between these beliefs and identifying their relationship with socioeconomic factors, depression, fatigue, and disability.

Section snippets

Experimental Design and Data Collection

This cross-sectional study was performed at three health care centers (two public and one private) and at the outpatient clinic of two industries. The inclusion criteria were as follows: the presence of chronic lumbar pain for a period of equal to or greater than 6 months, a minimum of 6 years of education, and normative communication and comprehension abilities. The principal investigator evaluated the communication abilities of the participants through observation; objective parameters were

Results

Two hundred fifteen individuals with chronic low back pain participated in this study. Of these patients, 70 (32.5%) were recruited from pain-specialized clinics, 77 (35.8%) were recruited from general clinics, 30 (13.9%) were recruited from occupational medicine, and 38 (17.7%) were industrial workers.

The majority of the sample was female (65.1%), under the age of 45 years old (50.7%), with a monthly family income between $450.00 and $1,350.00. Forty-four point two percent of patients were

Discussion

This study found that self-efficacy and fear avoidance beliefs were negatively correlated with each other and associated with certain factors such as income, depression, and disability. Other factors, such as gender and fatigue, were associated with only one of the beliefs.

Differences between men and women with regard to pain perception have been discussed in various studies. Women report experiencing more pain and show greater sensitivity and less tolerance to painful stimuli (Manson, 2010;

Acknowledgments

CAPES (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior [Coordination for the Improvement of Higher Education Personnel]) and CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico [National Counsel of Technological and Scientific Development]) financially supported this study.

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