The Tampa Scale of Kinesiophobia and neck pain, disability and ...

K HudesTroup and Bentley which attempts to “explain how andwhy some individuals develop a more significant psychologicaloverlay than others do.” 1, 2 The model explains thatavoidance of pain because of fear and the avoidance ofpainful activities (cognitive and behavioural avoidance)lead to physical and psychological consequences. 1 Thismodel has been widely used and supported.Kinesiophobia is a term that was introduced by Miller,Kori and Todd in 1990 at the Ninth Annual ScientificMeeting of the American Pain Society and describesa situation where “a patient has an excessive, irrational,and debilitating fear of physical movement and activityresulting from a feeling of vulnerability to painful injuryor reinjury.” 1,3 The Tampa Scale for Kinesiophobia (TSK)is a 17 item questionnaire used to assess the subjectiverating of kinesiophobia or fear of movement. 1,4,5 The originalquestionnaire was developed to “discriminate betweennon-excessive fear and phobia among patients withchronic musculoskeletal pain.” 3,4 Several studies havefound the scale to be a valid and reliable psychometricmeasure. 1,4,5 Initially used to measure fear of movementrelated to chronic low back pain, the TSK has been usedincreasingly for pain related to different body parts includingthe cervical spine. 6 The TSK is a self-completedquestionnaire and the range of scores are from 17 to 68where the higher scores indicate an increasing degree ofkinesiophobia. 6Initial research has concluded that the fear avoidancemodel may be predictive after acute whiplash injury regardingthe transition to chronic whiplash symptoms. 7For the practitioner who regularly treats patients withthis type of injury, it would be helpful to identify specific,easy and inexpensive tools to use to identify patients whoare at higher risk of developing chronic symptoms andkinesiophobia. The purpose of this narrative review ofthe literature was to review, and summarize the literatureregarding the use of the Tampa Scale of Kinesiophobiaand its relationship to neck pain, perceived disability andrange of motion of the cervical spine.MethodsAn initial search was performed on July 13, 2010 ofMedline, MANTIS and the Index to Chiropractic Literature(ICL). CINAHL was searched on August 17,2010 and these databases were searched for a secondtime to determine if the searches yielded any new articles.The following MeSH terms were used in the CIN-AHL, Medline and ICL searches: “Pain Measurement,”“Questionnaires,” “Severity of Illness Index,” “pain andPsychology,” “Avoidance Learning,” “Fear/Psychology,”“Neck Injuries,” “Neck Pain,” and “Cervical Vertebrae.”The following keywords were also used: “Tampa Scale ofKinesiophobia.” The only limiter used was English Languageonly articles in the searches.ResultsNumerous studies were identified regarding the TSK andmusculoskeletal pain. Far fewer were found regardingTSK in relation specifically to cervical spine pain. A totalof 16 studies, including one review of the literature, werefound using these inclusion criteria. These studies fell intofour distinct categories. The first category was TSK andneck pain which includes a total of 4 studies includingthe review mentioned above spanning from 2006 through2008. The second category is TSK, neck pain and disability(using the Neck Disability Index (NDI) or other measure)and includes 10 studies spanning 2004 through 2009.The last two categories are TSK, neck pain, disability andstrength and TSK, neck pain and surface EMG, each ofwhich include one study in 2009 and 2006 respectively.DiscussionEach of the 16 studies identified are discussed and summarizedbelow (Table 1).TSK and Neck PainThe first study in this section and one of the first studiesusing the TSK on neck pain patients was conductedby Buitenhuis, Jaspers and Fidler and published in 2006. 8Using the Dutch version of the TSK (TSK-DV) this oneyear prospective cohort study sent out 889 questionnairesto whiplash sufferers with neck symptoms from motorvehicle accidents from a Dutch insurance company. Sixtysixpercent of the studies were returned and 367 were usedfor analysis. The purpose of the study was to investigatethe “predictive value of early kinesiophobia on the durationof neck symptoms after a motor vehicle accident.” 8It was found that a higher score on the TSK-DV was associatedwith longer duration of neck symptoms but thatinformation on “early kinesiophobia does not improveprediction of duration of neck symptoms after a motorvehicle accident.” 8 Although this was the conclusion forJ Can Chiropr Assoc 2011; 55(3) 223

The Tampa Scale of Kinesiophobia and neck pain, disability and range of motion: a narrative review of the literatureTable 1 Study summaryStudy reference number(#),Publication date andAuthors Sample size Type of Study Objective Results and conclusion Limitations(6)September 2009Pool et. al.13 Inception cohort withbaseline assessmentTo determine the applicability of the TSKto neck pain– Supports the use of the fearavoidance model for neck pain– use of the ‘think aloud’ method to fillin questionnaire may confound results(7)2007Vangronsveld et. al.N/A Topical review Review of a few studies that investigatedthe applying the fear avoidance model tochronic whiplash syndrome– Supports the use of the fearavoidance model for neck pain– narrow focus of topical reviewregarding the use of the fear avoidancemodel for neck pain.(8)March/April 2006Buitenhuis et. al.367 Questionnaire investigate the “predictive value of earlykinesiophobia on the duration of necksymptoms after a motor vehicle accident– Higher TSK scores predictedincreased symptom duration.– Early Kinesiophobia does notimprove symptom prediction– used mailed questionnaires thereforeno control over situation in whichquestionnaire was completed.– participants contacted through insurer(MVA) which may influence scoring onquestionnaires.(9)November 2007Feleus et. al.679 Prospective cohort “determine if mean scores ofkinesiophobia change over time” inthose patients that they considered ‘nonrecovered’– Unrecovered subjects do notexhibit changing TSK scores overtime– no previous reports of value of TSKand neck, shoulder and arm pain.– number of variables may confoundstudy results.(10)March 2004Nederhand et. al.82 ProspectivelongitudinalInvestigate if fear avoidance variablesincrease prediction of chronic neck pain– The use of the NDI along withTSK can predict future neck painoutcomes– recruitment method and facility ofresearch may cause selection bias and/or symptom magnification.(11)2005Sterling et. al.80 Determine predictive capacity of the TSKmeasured early at long term follow up.– Higher NDI scores (withdecreased ROM (9)) and increasedpsychological distress/PTSD canpredict the persistence of symptoms/poor outcomes– recruitment method may causeselection bias and/or symptommagnification.– first study of its kind therefore resultshave yet to be confirmed.(12)2006Bunketorp et. al.47 RCT To determine the effect of individualizedsupervised physical training vs. homeself exercise on patients with subacutewhiplash– Self efficacy is an important factorin persistent neck pain disability– differences in exercise programsto supervised patients may exist asdifferent practitioners were used whichmay confound results.– Blinding not possible on patients ortreating physiotherapists which mayproduce bias– increased contact with treatingphysiotherapists in supervised groupwould increase level of patienteducation and may confound results.(13)March 2006Buketorp et. al.49 RCT To analyze the effects on disabilityof subacute whiplash patients fromthe different factors of pain(sensory,cognitive, affective)– Self efficacy is an important factorin persistent neck pain disability– differences in exercise programsto supervised patients may exist asdifferent practitioners were used whichmay confound results.– Blinding not possible on patients ortreating physiotherapists which mayproduce bias– increased contact with treatingphysiotherapists in supervised groupwould increase level of patienteducation and may confound results.– unclear if patients matched appropriatelyin consideration of this study224 J Can Chiropr Assoc 2011; 55(3)

K HudesTable 1 (Concluded)Study referencesnumber(#), Publicationdate and Author Sample size Type of Study Objective Results and conclusion Limitations(14)2006Sterling et. al.80 ProspectivelongitudinalAnalyze the predictive capacity of higherlevels of certain variables (older age, pain,disability, cold hyperalgisa, impairedsympathetic vasoconstriction andmoderate PTSD symptoms) at long termfollow up of whiplash injury.– Higher NDI scores (withdecreased ROM (9)) and increasedpsychological distress/PTSD canpredict the persistence of symptoms/poor outcomes– recruitment method and facility ofresearch may cause selection bias and/or symptom magnification.– unknown if findings can beextrapolated to other populations(15)February 2008Cleland et. al.78 Cohort Determine the value of using the FABQand TSK in neck pain patients– Supports the use of the fearavoidance model for neck pain– recruitment method and facility ofresearch may cause selection bias and/or symptom magnification.– test-retesting may have been done tooclose together promoting bias.(16)2006Gustavsson, C and vonKoch, L.37 RCT To examine the usefulness of thisparticular study design (RCT) inevaluating patients with long term neckpain and compare the effects of treatment.– Applied relaxation group hadbetter perceived control over pain– Self efficacy is an important factorin persistent neck pain disability– preliminary study therefore smallsample size(17)May 2008De Loose et. al.629 Questionnaire (crosssectional)Estimate the prevalence and identify riskfactors of neck pain in military officeworkers– neck pain is prevalent in militaryoffice workers and psychosocialfactors are more important in theshort term– used mailed questionnaires thereforeno control over situation in whichquestionnaire was completed.– population may have a reluctance toadmit to pain and disability/fear.(18)2009Nieto et. al.147 Questionnaire Identify if fear of movement and paincatastrophizing predict disability anddepression in subacute whiplash patients.– Supports the use of the fearavoidance model for neck pain– recruitment method and facility ofresearch may cause selection bias and/or symptom magnification.– long term follow up needed.(19)2009Vernon et. al.107 Cross sectional design Used chronic whiplash patients todetermine if fear avoidance behaviourand pain amplification along withseveral factors (age, gender, duration andpain severity) correlate with perceiveddisability.– Supports the use of the fearavoidance model for neck pain– focused on chronic neck pain andsubjects entered study after referral forthird party specialist assessment whichmay produce selection bias.(20)March 2009Pearson et. al.14 WAD28 healthypatientsCross sectionalrepeated measuresdesignTo determine if there is a link betweenneck strength measurements and pain,kinesiophobia and castastrophizing inWAD patients– No significant association wasfound between TSK/NDI and neckstrength– 3 of 6 muscles tested in chronicWAD showed decreased strengthcompared to healthy subjects.– recruitment method and facility ofresearch may cause selection bias and/or symptom magnification.– most WAD sufferers were in driver’sside collisions which may produce biasto which muscles affected(21)August 2006Nederhand et. al.92 Prospectivelongitudinal designTo determine the influence of pain andfear of movement on activation patternsof the upper trapezius muscle during thetransition from acute to chronic neck pain– Supports the use of the fearavoidance model for neck pain– Supports the use of the painadaptation model for neck pain– use of sEMG which is currentlyclassified as an experimental assessmenttechnique by the American Academy ofNeurologists.– recruitment method and facility ofresearch may cause selection bias and/or symptom magnification.J Can Chiropr Assoc 2011; 55(3) 225

The Tampa Scale of Kinesiophobia and neck pain, disability and range of motion: a narrative review of the literaturethe study, it was noted that a relationship does exist betweenthe TSK score and the duration of neck symptoms.However, when other variables were accounted for suchas sex and age, the significance was lost. These variableshave been previously shown to have a relationship to neckpain duration. 8 It was also noted that there was a relationshipbetween TSK score and symptom intensity as well asdifficulty with concentration and initiation of sleep. Thisstudy utilized mailed questionnaires to victims of motorvehicle accidents and were contacted through a Dutch insurancecompany. Although the authors maintain that itwas made clear on the letter of invitation to the study thatinvolvement would be independent of compensation fromthe insurer regarding the claim, one cannot be sure thatsymptom exaggeration was not present in responses. Inaddition, as the study was mailed, the authors identifiedthat there was no control of the environment under whichthe questionnaires were completed.In 2007, Feleus, van Dalen, Bierma-Zeinstra, Bernsen,Verhaar, Koes and Miedema used a prospective cohort designto describe the degree of kinesiophobia in patientswith non-traumatic complaints of arm, neck and shoulderin general practice. 9 The study used the 13 item adjustedDutch version of the TSK (TSK-AV). The aim wasto “determine if mean scores of kinesiophobia changeover time” in those patients that they considered “non-recovered.”9 Additionally they sought to evaluate variablesincluding age, gender, educational level, work, sports participation,duration of complaint, severity of complaint, aswell as psychosocial characteristics and their associationwith kinesiophobia at baseline. The category of recurrentcomplaint was also included and accounted for not onlyrecurrent complaints, but also multiple complaints andcomplaint location. The study evaluated 36 patients witha new complaint or episode of neck, upper back, shoulder,upper arm, elbow, forearm, wrist or hand pain aged18 to 64 years. Excluded from the study were those withpain that could be explained. The patients completed aninitial questionnaire and then again at 6 and 12 month followup. It was found that the degree of kinesiophobia wasunchanged in patients who did not recover during the 12month follow up. Limitations include the lack of previousreports of the psychometric value of the TSK with respectto neck, shoulder and arm pain, the lack of measurementof depression in the patients and the use of one question togive an indication of “health locus of control.” Relationshipswere noted between baseline scores of kinesiophobiaand catastrophizing, disability and other musculoskeletalcomplaints/comorbilities. This said, it was noted that thismade it unclear if the origin of kinesiophobia was rootedin the other comorbilities (low back pain) or a previousbad experience. Although the authors reported that thesecomorbilities did not modify the association, the highnumber of variables in this study could have confoundedresults. In addition, the study was not limited to neck painonly patients and included patients with arm and shouldercomplaints. This could artificially inflate relationships betweenkinesiophobia and neck pain as patients frequentlyhave difficulty separating these types of symptoms andtheir effects.In 2007 Vangronsveld, Peters, Goossens, Linton andVlaeyen published a topical review “Applying the fearavoidancemodel to the chronic whiplash syndrome.” 7 Thisreview sought to review what the authors considered to berelevant studies that examined whether the fear avoidancemodel can be applied to chronic whiplash syndrome. Allof the studies examined in this review will be examined indetail in this paper. It was concluded that the fear avoidancemodel “may offer a novel framework to explain thetransition from acute whiplash injury to chronic whiplashsyndrome.” 7 It was suggested that future research shouldinclude multiple outcome measures as patients who sufferan acute whiplash not only are at risk of developing highpain levels and disability but also mood disorders and posttraumatic stress disorder. Suggestions for future researchinclude determining if high levels of catastrophizing soonafter a whiplash injury lead to more complaints at finalfollow up, as well as studying other potential predictors(anxiety sensitivity and acute traumatic stress symptoms).This review included only a few studies as it was a topicalreview. The limitation is primarily that by its nature, atopical review provides a small window into the research.Pool, Hiralal, Ostelo, van der Veer, Vlaeyen, Bouterand de Vet published a study regarding “The applicabilityof the Tampa Scale of Kinesiophobia for patientswith sub-acute neck pain” in 2009. 6 This study sought to“qualitatively evaluate patients” understanding and interpretationof the wording in test items of the TSK” whichwas initially developed to measure fear of movement ofpatients suffering from low back pain. It attempted toelicit or discover problems that patients with sub-acuteneck pain may have in filling out the TSK . Thirteen226 J Can Chiropr Assoc 2011; 55(3)

K Hudespatients (7 women and 6 men) aged 18 to 70 were evaluatedusing the Three-Step Test Interview (TSTI) which aims toidentify problems with self-administered questionnaires.It was reported that two problems were identified includingthe use and meaning of specific words such as “dangerous”and “injury” as well as that implicit assumptionswithin some items make it difficult for some respondentsto answer these questions. The authors concluded that inthe “development and validation of questionnaires such asthe TSK not only qualitative psychometric properties areimportant, but also qualitative research has an importantcontribution to enhance applicability.” 6 Questionnaires inthis study were filled out using a “think aloud” methodwhich the authors reported proved difficult for some participants.By its nature, this method may cause participantsto become uncomfortable if they feel they are beingjudged by the study investigators which may influencetheir verbalizations. It was reported that some participantsanswered quickly while others did so slowly but it wasnot reported if any specific participant characteristic (age,gender) was related to this.TSK, Neck Pain and DisabilityIn 2004 Nederhand, IJzerman, Hermens, Turk and Zilvoldattempted to determine the “Predictive value of fearAvoidance in developing chronic neck pain disability.” 10Using an inception cohort design with a baseline assessmentone week post trauma and outcome assessment at24 weeks post trauma, the purpose of this study was toimprove clinical decision making in patients with posttraumatic neck pain by investigating fear avoidance inpredicting neck pain disability. 10 Ninety-one percent ofthe 90 participants between the ages of 18 and 70 in thestudy completed the follow up outcome. It was found thatby using a combination of baseline NDI and TSK scoresit was possible to predict chronic disability with a probabilityof 54.2% after using NDI alone and 83.3% whenusing a combination of NDI and TSK scores. The authorsconcluded that a “rating of neck pain disability within aweek of trauma used separately or in combination witha test for fear of movement can be used to predict futureoutcomes.” 10 This finding is opposite to the first study discussedabove by Buitenhuis in 2006. However, unlike thepreviously discussed study this study excluded patientswith neurologic signs and focused on head and neckpain alone. Limitations of this study include recruitmentmethod (patients admitted to the emergency departmentof a hospital) and the fact that the study was conducted ata well known rehabilitation and research facility. Thesecharacteristics may well lend to symptom magnificationand/or have a tendency towards selection bias of thosemore prone to catastrophizing or symptom magnification.In 2004, Sterling, Jull, Vicenzino, Kenardy and Darnellinvestigated “physical and psychological factors(that) predict outcome following whiplash injury.’ 11 Thisprospective longitudinal designed study investigated 80patients with a mean age of 36.27+/–12.69 years that reportedneck pain as a result of a motor vehicle accident.The purpose of this study was to determine the predictivecapacity of the combined comprehensive set of measuresthat included motor, sensory and psychological measuresencompassing the broad biopsychosocial model of musculoskeletalpain. Measures used included motor functioning(range of motion, kinesthetic sense, and activity ofsuperficial neck flexors on EMG), sensory testing, vasoconstrictorresponses, psychological distress (includingvarious measures along with the TSK) and the NDI. Theoutcome measure was persistent pain at six months postinjury. It was concluded that “higher NDI scores, greaterpsychological distress and decreased range of motionpredicted subjects with persistent milder symptoms fromthose who fully recovered.” 11 The authors suggested thatboth “physical and psychological factors play a role inrecovery or non-recovery from whiplash injury.” 11 Whena combination of the variables was used, the predictivevalue was better than when compared to previous modelsthat did not use all of these variables. The authors reportedthat they could account for 67% of the variationin pain and disability using this model compared to 35%when using a combination of age, gender, psychologicalfactors or age, gender and accident features. As this studywas the first of its kind, that being the first to show thatphysical and psychological factors when added to previouslyknown factors (age and initial symptom intensity)are important in predicting outcomes of whiplash injuries,confirmation of results are needed. Interestingly, higherpain reports were predicted by cervical range of motionloss. This was the only motor function that predicted longterm outcomes while EMG activity in flexion of the cervicalspine and joint position error were not isolated toonly WAD sufferers with higher level of pain symptoms.The limitation for this study is similar to that of the studyJ Can Chiropr Assoc 2011; 55(3) 227

The Tampa Scale of Kinesiophobia and neck pain, disability and range of motion: a narrative review of the literaturepublished in 2004 by Nederhand et. al. above as patientswere recruited following a motor vehicle accident in hospitalemergency rooms; however, this effect is lessenedas people were also recruited from primary care practice,and advertisement.Bunketorp, Lindh, Carlsson and Stener-Victorin firstused the results of their randomized controlled trial using40 subjects in a publication in 2005. 12 The purpose of thestudy was to evaluate if a tailored and supervised physicaltraining program had a greater influence on self efficacy,fear of movement and re-injury than a self administeredhome exercise program. The study used the Self EfficacyScale and the TSK as primary measures and thePain Disability Index as a secondary measure. It was reportedthat the supervised training was significantly moreeffective than the home training program” with a morerapid improvement in self efficacy and fear of movementat three months and that the results were partially maintainedat nine months.” This was the only study elicitedin the literature search that measured the outcomes oftreatment with the TSK for neck pain. Improvement inkinesiophobia, perceived disability due to pain, self efficacyand analgesic use was noted to be significant in thegroup that received a tailored supervised exercise programcompared to the home exercise group. Although theinvestigator performing measurements was blinded to thegroup the patient was in, due to the nature of the study, thefive treating physiotherapists and the patients could notbe blinded which may have influenced outcomes. As fivedifferent physiotherapists were used to provide treatment,and the group getting tailored treatment each had differentprograms, it is unclear if each patient in the supervisedtraining group was provided with equally effective programs.In addition, the added contact between the supervisedgroup and physiotherapists would provide increasededucation levels to these patients as it would be near impossiblefor the practitioner not to continue to educate thepatients. It is therefore a confounding factor as it cannotbe definitively said that the exercise program differencesaccount for the significant differences in groups as patienteducation would also be a likely factor in the differencesseen.In 2006, the same investigators (Bunketorp et. al.) usedthe data collected in for their 2005 study to “clarify relationsbetween sensory, affective and cognitive dimensionsof pain and to analyze what influence these componentshave on persistent disability in patients with sub-acutewhiplash associated disorder.” 13 It was reported that “selfefficacy was the most important predictor of persistentdisability.” 13 Additionally the following factors werefound to correspond to lower self efficacy: high pain intensityand pain affect, widespread pain and fear of movement.As the same data was used as in the previous study,it begs the question were the investigators planning thiscomponent of the research prior to the investigation or didthey use existing data because a relationship was noted.If the latter is the case, bias may be present as the groupsmay not have been matched effectively to investigate thisportion of the research. In addition, all of the same limitationslisted above would also apply to this study.The predictive value of variables including initialhigher levels of pain and disability, older age, cold hyperalgesia,impaired sympathetic vasoconstriction and moderatepost-traumatic stress symptoms were investigated ina study published in 2006 by Sterling, Jull and Kenardy. 14The investigators noted that while these variables havebeen shown to be associated with poor outcomes at 6months post whiplash, investigation of associations at longterm follow up was lacking. This study used a prospectivelongitudinal design to follow and assess 80 acute whiplashpatients to 2, 3, and 6 months post injury and againat 2–3 years post injury. The study employed the TSK andNDI as well as cervical range of motion, joint positionerror, pressure pain and thermal thresholds and measuresof the sympathetic nervous system function (sympatheticvasoconstrictor response). It was concluded that “higherinitial NDI scores, older age, cold hyperalgesia and posttraumatic stress symptoms were significant predictors ofpoor outcome at long term follow up” 14 When the TSKalong with Impact of Events Scale and the General HealthQuestionnaire 28 were used it was found that there wasa “significant group effect for the group with moderate/severe symptoms at 2–3 years when compared to groupswith milder symptoms.” 14 As it was noted that the physicaland psychological characteristics of those who did notrecover at 6 months and long term follow up were presentat one month post injury, it was implied that this posessignificant implications for early management of this typeof patient. The authors suggest that this group of patientsmay benefit from early multidisciplinary management toinclude adequate pain control using pharmacotherapy,physical and psychological therapy. Subjects were re-228 J Can Chiropr Assoc 2011; 55(3)

K Hudescruited from emergency departments following a motorvehicle accident (as well as their primary care physiciansand advertisements) which may produce a bias towardsthose with symptom magnification. It was reported by theauthors that the findings in a small group of whiplash patientsmay not extrapolate to expand to other populations.In 2008 Cleland, Fritz and Childs attempted to examine“the psychometric properties of the Fear Avoidance BeliefsQuestionnaire (FABQ) and the TSK in Patients withneck pain.” 15 Using a cohort design, 78 subjects wereasked to complete the Fear Avoidance Beliefs QuestionnaireWork (FABQW) and Physical Activity (FABQPA)as well as the TSK at baseline and 2 day follow up. Itwas reported that “the FABQW and FABQPA had subsettest-retest reliability and the TSK was moderately reliablefor neck pain patients.” 15 Consistency was found forall measures. The authors concluded that this study suggesteda “weaker relationship between measures of fearand avoidance and pain/disability in patients with mechanicalneck pain than has been reported among patientswith lower back pain.” 15 The authors identified limitationsof the study including the inclusion of sub-acute neck painpatients which they felt may have influenced the results aswell as the fact that the dimensionality of the scales werenot assessed. This factor affects the statistical tool theyused (Cronbach’s alpha), which they felt may account forlower TSK scores in comparison to the other measuresthey used. It was also noted that subjects included wereconsecutive patients presenting to a hospital physiotherapydepartment with history of a whiplash injury within6 weeks. This may present a bias towards patients withsymptom magnification. The follow up testing was doneonly 2 days following initial testing which may not proveto be a significant enough amount of time between testsas patients may have a tendency to recall what they scoredonly two days prior. It would be interesting to have repeatedthis measure a more significant amount of timelater such as one to three months.Gustavsson and von Koch used measures of neck pain,TSK and NDI to “evaluate the feasibility of study designand method for evaluating effects of interventionson patients with long lasting neck pain and to comparethe treatment effects of (i) a pain and stress managementgroup intervention with applied relaxation and (ii)individual physiotherapy treatment as usual.” 16 Using arandomized controlled pilot study, the authors evaluated37 patients with long lasting neck pain. Patients wereassigned to either an applied relaxation group which received7 group sessions over 7 weeks or the “as usual”group who had an average of 11 physiotherapy sessionsover 20 weeks. Using the NDI, Coping Strategies Questionnaire,Hospital Anxiety and Depression Scale, TSKand questions regarding neck pain, analgesic use, sleep,sick leave and health care utilization, it was found thatthe applied relaxation group had “better perceived controlof pain” at 20 week follow up compared to the “asusual” group. The authors concluded that “this design andmethods would be suitable for a larger RCT study.” 16 Thelimitations of this study is that of its preliminary natureand small sample size for each group.In 2008 De Loose, Burnotte, Cagnie, Stevens, VanTiggelen and Defense used a cross sectional questionnairestudy of 942 office workers of the Belgian Defenseto attempt to identify short and long term risk factors inthe occurrence of neck pain in military office workers. 17Using the NDI and TSK to assess the impact of neck painon the respondent’s life and pain-related fear avoidance itwas concluded by the authors that the results “supportedthe role of physical and psychosocial job characteristicsin the etiology of neck pain in military office workers.” 17It was noted that in those that did respond (147 of 942)neck pain is common. As this was a questionnaire thatwas sent out, the study could not control the environmentin which the questionnaire was filled out which may haveinfluenced results. In addition, as it was sent to militaryworkers, the population may have a reluctance to admit topain, fear and disability.Using a stepwise regression analysis, Nieto, Miro andHuguet analyzed the “fear-avoidance model in whiplashinjuries” in a publication in the European Journal of Painin 2009. 18 The purpose of the study was to determine if“fear of movement and pain catastrophizing predict painrelated disability and depression in sub-acute whiplash patients.”While controlling for descriptive variable and paincharacteristics, 147 sub-acute whiplash patients betweenthe ages of 18 and 65 completed the Pain CatastrophizingScale (PCS), TSK, NDI and the Beck Depression Inventory(BDI) and current neck pain was recorded on an 11point numeric scale where 0 is “no pain” and 10 was “painas bad as could be.” It was found that “catastrophizing andfear of movement were predictors of disability and depression”and that “pain intensity was a predictor of dis-J Can Chiropr Assoc 2011; 55(3) 229

The Tampa Scale of Kinesiophobia and neck pain, disability and range of motion: a narrative review of the literatureability but not depression.” 16 The authors concluded thatas the fear avoidance model suggests, fear of movementand catastrophizing are important factors with respect todeveloping disability and depression in whiplash patients.The study used whiplash sufferers who were involved in acar accident with pain of less than three months durationwho were seeking treatment in rehabilitation facilities. Asthese participants were already seeking treatment, there isthe possibility that this population may have a bias towardsymptom magnification. This study provides data for asmall period of time, namely whiplash of less than threemonths duration. Further study is required to determine ifthe relationships identified continue over time.Vernon, Guerriero, Kavanaugh, Soave and Moretonattempted to “determine if fear avoidance behavior andpain amplification along with age, gender, duration andpain severity correlate with sources of self rated disabilityin chronic whiplash sufferers.” 19 Published in 2009, thisstudy used a cross sectional clinical study design examined107 subjects with a mean age of 45.5 years who completedthe NDI, TSK, pain visual analogue scale and paindiagram. It was concluded by the authors that “importantpsychological factors including fear avoidance beliefsand pain amplification have some influence on self rateddisability in chronic whiplash sufferers, (though this influencewas not) larger than that found in studies of acute/sub-acute patients.” 19 The authors report that it is not yetclear how fear avoidance behaviour and pain amplificationinfluence perceived disability in chronic WhiplashAssociated Disorder (WAD) though they have influenceon its development. The study focused on chronic patientsat least three months post WAD who were referred to thestudy after presentation for a third party specialist assessment.This may have produced a selection bias.TSK, Neck Pain, Disability and StrengthThe only study found in the literature to be included inthis section was published in 2009 by Pearson, Reichert,De Serres, Dumas and Cote. 20 In this controlled laboratorycross-sectional, repeated measures design 14 subjectswith chronic whiplash grades I and II were agematched with a healthy group and cervical strength wasmeasured in 6 directions with a Multi-Cervical Unit. Painwas measured using a Visual Analog Scale and the WADgroup completed the NDI, TSK and Pain CatastrophizingScale (PCS). It was found that the WAD group had“significant deficits in strength” compared to the healthygroup especially in extension and lateral flexion but that“no significant association between neck strength andNDI, TSK and PCS was found.” 20 The study did identifystrength deficits in WAD sufferers ranging from 52% to72% in extension, retraction and left lateral flexion. Theauthors had difficulty explaining the reason behind deficitsin left lateral flexion and reported that the majority ofthe sample had driver’s side collisions. This study shouldtherefore be repeated with subjects who were in variouspositions of the car with various types of impacts as differentmuscles may be affected depending on position,seat belt position and direction of impact. The study alsorecruited chronic WAD sufferers from rehabilitation andreturn-to-work program which may have caused a selectionbias.TSK, Neck Pain and Surface ElectromyographyThe last study to be reviewed, and the only one in thissection was published by Nederhand, Hermens, Ijzerman,Groothuis and Turk in 2006. 21 The purpose of this studywas “to evaluate the role of pain and fear of movementin the muscle activation pattern of the upper trapeziusmuscle during the transition of acute to chronic post traumaticneck pain.” Using a prospective longitudinal design92 subjects with acute traumatic neck injury after MVAwere followed up for 24 weeks. Using a Visual Analogscale rating of pain, TSK and surface Electromyography(sEMG) during sub-maximal isometric activation of thetrapezius muscle. Subjects were evaluated at 1, 2, 8, 12,and 24 weeks. The results indicated that lower levels ofmuscle activity was independently associated with boththe increase in fear of movement and pain intensity. Interestingly,it was reported that patients reporting higherpain intensity had a stronger association between fear ofmovement and decreased muscle activity which appearsto decrease as time passed since the injury. The authorsconcluded that both the pain adaptation and fear avoidancemodels were supported by their results. This studyused sEMG which is currently classified as an experimentalassessment technique by the American Academyof Neurologists. While less invasive than needle EMG,needle EMG remains the gold standard for this type oftesting. The sample of patients was recruited from a hospitalemergency room after a motor vehicle accident,which, like in many of the other studies may produce a230 J Can Chiropr Assoc 2011; 55(3)

K HudesTable 2 Summary of study findings or conclusionsFindings or ConclusionsStudy referenceHigher TSK scores predicted increased symptom duration 8Early Kinesiophobia does not improve symptom prediction 8Unrecovered subjects do not exhibit changing TSK scores over time 9Supports the use of the fear avoidance model for neck pain 7, 15, 18, 19, 21The use of the NDI along with TSK can predict future neck pain outcomes 10Higher NDI scores (with decreased ROM (9)) and increased psychologicaldistress/PTSD can predict the persistence of symptoms/poor outcomes 11, 14Self efficacy is an important factor in persistent neck pain disability 12, 14No significant association was found between TSK/NDI and neck strength 20Supports the use of the pain adaptation model for neck pain 21selection bias towards those with tendencies for painamplification or catastrophizing. The authors report thatas a result of this study, reclassification of the Quebec TaskForce injury severity classification system is required asthey found that WAD II “is not characterized by musclespasm but rather by muscle recoordination.” Further studyand confirmation possibly using needle EMG is requiredprior to the implementation of this recommendation.The findings or conclusions from the studies reviewedhave been summarized in table 2.ConclusionThe TSK was originally developed to measure the fearof movement with respect to low back pain sufferers. Aspreviously stated, the TSK has been used more recently tomeasure kinesiophobia in different body parts includingthe neck. There have been only 16 studies conducted regardingneck pain and the TSK in general that were foundduring the research phase for this review. Despite this,preliminary research has shown that there is value froma psychometric perspective in using the TSK with neckpain patients. It also seems that the fear avoidance modelcan be applied to neck pain sufferers from the initial researchconducted. The TSK has been used with measuresof perceived disability including the NDI to measure howkinesiophobia and neck pain are related to perceived disability.Further research is needed to determine if, and towhat extent, other measureable factors commonly associatedwith neck pain, such as decreased range of motion,correlate with kinesiophobia. Several of the studies currentlyavailable used recruitment methods that may haveinduced a bias. Although WAD is a common cause ofneck pain, it is not the only cause of neck pain. The studiesreviewed have a heavy bias towards the use of WADsufferers in their research. It would be advisable thatfuture research use neck pain sufferers from other causesas well. This review has identified some areas of researchincluding neck range of motion, strength, and muscle activationwith regard to fear of movement and the TSK thatrequire further study.AcknowledgementsI would like to thank Dr. Howard Vernon for guidance,Ms. Anne Taylor-Vaisey research librarian for assistancein researching this review and Mr. Ken Clasper andMs. Anne Taylor-Vaisey for their general assistance withproof reading.References1 Lundberg MKE, Styf J, Carlsson SG. A psychometricJ Can Chiropr Assoc 2011; 55(3) 231

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