Teoría de las tres dimensiones del concepto de desarrollo sostenible

Introduction  

The  first  aim  of  this  research  was  to  explore  the  beliefs  underlying  pain-­‐related   fear  amongst  participants  with  CNSLBP  and  high  pain-­‐related  fear.      

Participants   with   high   pain-­‐related   fear   were   identified   for   inclusion   in   this   study   based   on   scores   on   the   TSK,   widely   believed   to   be   a   measure   of   fear   of   movement/(re)injury,   defined   as   a   specific   fear   of   movement   and   physical   activity  that  is  (wrongfully)  assumed  to  cause  (re)injury  (Vlaeyen  et  al.  1995).   During   the   participant   interviews,   it   became   apparent   that   not   all   of   the   participants   selected   on   the   basis   of   a   high   TSK   score   were   afraid   that   movement   and   physical   activity   would   cause   (re)injury.     This   raised   the   question:  what  does  the  TSK  measure?    

A  lack  of  conceptual  and  operational  definition  of  the  TSK  has  been  highlighted   previously  by  Lundberg  et  al.  (2011)  who  called  for  future  research  combining   psychometric   procedures   with   qualitative   approaches   that   incorporate   the   patients’   perspective   to   help   reach   an   agreement   on   the   definitions   of   construct(s)  measured  by  the  TSK.  

The   publication   that   follows   answers   this   call.   In   addition   to   describing   the   beliefs  underlying  high  pain-­‐related  fear,  a  mixed-­‐methods  analysis  explores  the   construct  validity  of  subscales  on  the  TSK.    

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

What Do People Who Score Highly on the Tampa Scale

of Kinesiophobia Really Believe?

A Mixed Methods Investigation in People With Chronic Nonspecific

Low Back Pain

Samantha Bunzli, Bphty (hons),* Anne Smith, PhD,* Rochelle Watkins, PhD,w Robert Schu¨tze, MPsych(Clinical),z

and Peter O’Sullivan, PhD*

Objectives: The Tampa Scale of Kinesiophobia (TSK) has been used to identify people with back pain who have high levels of “fear of movement” to direct them into fear reduction interventions. However, there is considerable debate as to what construct(s) the scale measures. Somatic Focus and Activity Avoidance subscales identified in factor analytic studies remain poorly defined. Using a mixed methods design, this study sought to understand the beliefs that underlie high scores on the TSK to better understand what construct(s) it measures.

Methods: In-depth qualitative interviews with 36 adults with chronic nonspecific low back pain (average duration = 7 y), scoring highly on the TSK (average score = 47/68), were conducted. Fol- lowing inductive analysis of transcripts, individuals were classified into groups on the basis of underlying beliefs. Associations between groups and itemized scores on the TSK and subscales were explored. Frequencies of response for each item were evaluated. Findings: Two main beliefs were identified: (1) The belief that painful activity will result in damage; and (2) The belief that painful activity will increase suffering and/or functional loss. The Somatic Focus subscale was able to discriminate between the 2 belief groups lending construct validity to the subscale. Ambiguous wording of the Activity Avoidance subscale may explain limitations in dis- criminate ability.

Discussion: The TSK may be better described as a measure of the “beliefs that painful activity will result in damage and/or increased suffering and/or functional loss.”

Key Words: chronic low back pain, fear avoidance model, pain- related fear, Tampa Scale of Kinesiophobia, qualitative research, mixed methods

(Clin J Pain 2015;31:621–632)

I

n a survey of Australian adults, 65% reported at least 1 episode of low back pain in the previous 6 months, with 16% reporting chronic disabling low back pain.1_Estimates

suggest that only 8% to 15% of patients with chronic low back pain have an identified pathoanatomic diagnosis,2 leaving >85% being classified with chronic nonspecific low back pain (CNSLBP).3

The theory of reasoned action states that beliefs about the consequences of behavior have a strong influence on behavioral intention.4 Consistent with this, a leading explanation of pain persistence and disability in CNSLBP is the fear avoidance model (FAM).5_{This cognitive-behav-}

ioral model describes how the “catastrophic” interpretation of pain as a sign of damage catalyses a vicious cycle of fear and avoidance. The avoidance of movement or activities associated with pain reduces opportunities for positive exposure, sustaining pain and disability.

The Tampa Scale of Kinesiophobia (TSK)6_{is a widely}

used measure of pain-related fear beliefs.7High scores on the TSK have been found to be associated with and pre- dictive of increased pain severity,8 _{pain duration,}9 _and

increased CNSLBP disability.9,10Longitudinal analysis has shown that reductions in scores for pain-related fear predict reductions in disability.11

However, there is considerable debate as to what construct(s) the TSK actually measures.12 _{The TSK was}

developed before publications of the FAM and was initially designed as a 1-dimensional scale of Kinesiophobia: “an excessive, irrational and debilitating fear of physical movement and activity resulting from a feeling of vulner- ability to painful injury or re-injury.”13_{In the context of}

CNSLBP, it is more widely considered a measure of fear of movement/(re)injury defined as a specific “fear of move- ment and physical activity that is (wrongfully) assumed to cause (re)injury.”14

Further, rather than being a 1-dimensional scale, fac- tor analytic studies involving people with CNSLBP have favored a 2-factor model of the TSK in which the broader construct fear of movement/(re)injury is represented by the subscales Somatic Focus (TSK-SF) and Activity Avoidance (TSK-AA).15–17_{The subscales, however, have been incon-}

sistently described.12The TSK-SF has been described as: “the belief in underlying and serious medical problems”18

as well as “the belief that pain is a sign of bodily harm or damage.”19The TSK-AA has been described as: “the belief that activity may result in (re)injury or increased pain”18_as

well as “the belief that activities that promote pain should

Received for publication December 10, 2013; revised July 22, 2014; accepted July 22, 2014.

From the *School of Physiotherapy and Exercise Science; zSchool of Psychology and Speech Pathology, Curtin University, Perth; and wTelethon Institute for Child , Centre for Child Health Research, The University of Western Australia, West Perth, WA, Australia. S.B. is the recipient of an Australian Postgraduate Award and Curtin

University Postgraduate Scholarship. The authors declare no con- flicts of interest.

Reprints: Samantha Bunzli, Bphty (hon), School of Physiotherapy and Exercise Science, Curtin University, GPO Box U1987 Perth, WA 6845, Australia (e-mail: [email protected]. edu.au).

Copyrightr_{2014 Wolters Kluwer Health, Inc. All rights reserved.} DOI: 10.1097/AJP.0000000000000143

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Clin J Pain_{Volume 31, Number 7, July 2015 www.clinicalpain.com}|₆₂₁

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. be avoided.”19_{Further, French et al}19_{found the TSK-SF}

and the TSK-AA highly correlated with each other and other measures including catastrophizing and depression questioning the clinical utility of distinguishing between them. These definitions remain to be confirmed through rigorous qualitative investigation.

Interventions studies have used the TSK as an assessment tool to identify individuals with high fear of movement/(re)injury for interventions aimed at reducing fear of movement/(re)injury such as cognitive-behavioral therapy, graded exposure, and graded activity.20–22There is some evidence that these interventions are effective in reducing fear of movement/(re)injury.21,23 _{However, the}

literature has highlighted substantial costs associated with highly personalized treatment such as graded exposure, and calls have been made for treatment matching to ensure that valuable resources are not wasted.24 Treatment matching infers that only people with “specific characteristics” receive tailored fear reduction treatments.24_{However, there is little}

guideline in the literature as to what these specific charac- teristics are, beyond scoring highly for fear of movement/ (re)injury.

This study sought to understand the beliefs that underlie high scores on the TSK to better understand what construct(s) the TSK measures. The first aim of this paper was to describe how individuals scoring highly on the TSK interpret the CNSLBP experience and its consequences in qualitative one-on-one interviews. The second aim was to explore how individual variance in qualitative interview data relates to elevated scores on the TSK and scores on the TSK-AA and TSK-SF subscales.

METHOD

Interpretive Description (ID) is a qualitative method- ological framework based on the epistemological founda- tions of client-centered health research. It adheres to the systematic reasoning of health disciplines with the aim of yielding legitimate knowledge for clinical practice. Rather than loosely adapting methodological frameworks bor- rowed from disciplines such as sociology or anthropology, ID makes explicit its departure from traditional qualitative methodologies. Foremost, in contrast to phenomenological approaches, ID acknowledges that the health researcher necessarily brings theoretical and practical knowledge to the study and lays visible the a priori beliefs and assump- tions of the researchers that influence the design and find- ings of the study. The authors of this paper are clinical and research physiotherapists and a clinical psychologist with interests in the clinical application of biopsychosocial models of chronic pain. S.B., a physiotherapist, conducted and transcribed all interviews and led the data analysis, with input from all 4 coauthors. The ID framework allowed the researchers to use their knowledge of the FAM, both evidence-based and empirical, to design a study that could investigate individuals’ interpretation of the CNSLBP experience and its consequences, with implications for clinical practice.

ID also acknowledges that at the foundation of clinical knowledge is the recognition that health experiences com- prise complex interactions between biological, psycho- logical, social phenomena. Shared patterns of such experi- ences are at the core of clinical knowledge, while the application of clinical knowledge will be individualized for each patient.25In this context, ID seeks to reveal shared

patterns of experiences that have clinical application but “remain amenable to reconsideration in the light of varying contexts, new concepts, new ways of understanding, and new meanings.”25p.172

Approval for this research was granted by the Curtin University Human Research Ethics Committee (approval number HR65/2011) and local hospital ethics committees in Perth, WA.

Sample

Purposive sampling was used to recruit participants seeking care from a variety of musculoskeletal practitioners including general practitioners, physiotherapists, chiro- practors, and multidisciplinary pain centers in Perth, WA. A wide sample frame was used as pain-related fear and has been shown to be associated with increased care-seeking in an Australian sample.1

Adults aged 18 to 65 years with a CNSLBP of Z6 months duration and pain intensity Z3/10 on the Visual Analogue Scale were eligible for inclusion. Individuals who presented with specific causes of low back pain including red flags, radicular pain with nerve compression, and spondylolisthesis and pregnancy-related back pain were excluded. Individuals who met the inclusion criteria were screened with the 17-item TSK13to identify those with high pain-related fear defined as a score of Z40. This cutoff is above suggestions from a recent review paper that a score of >37 reflects high pain-related fear,26 but aligns with previous research by Vlaeyen et al.23

Procedure

Individuals meeting the inclusion criteria were identi- fied by clinicians at the participating centers between May 2012 and May 2013. They were provided with the study information sheet and were invited to contact the researchers if they were interested in participation.

Purposive sampling was used to ensure that partic- ipants seeking care from a range of health settings were included. This paper describes the experiences of 36 indi- viduals who gave written informed consent and partici- pated in the study. The participants were 69% female with an average of 42 years of age. The mean duration of CNSLBP was 7 years and the mean score on the TSK was 47/68. Demographic data for each participant are presented in Table 1.

Data Collection

Data were provided from semistructured interviews in which the interviewer opened with the question “Can you please tell me your pain story?” This assisted the participant to feel at ease and gave the researcher a deeper contextual understanding of the individuals’ experience. The inter- views explored the nature of their pain, their pain beliefs, and their beliefs about the function of their back and the causes and consequences of their back pain. An interview schedule used as a guide to prompt discussion can be seen in Table 2.

Interviews were held predominantly in the partic- ipants’ homes. In 2 cases interviews took place in the office of the first author (S.B.) and phone interviews were con- ducted with 2 participants living in a rural location. Inter- views lasted between 45 minutes to 2 hours. No differences were noted between the content or depth of the interviews conducted in the participants’ home, the researchers’ office or phone interviews.

Bunzli et al Clin J Pain _{Volume 31, Number 7, July 2015}

622|_{www.clinicalpain.com Copyright}r_{2014 Wolters Kluwer Health, Inc. All rights reserved.}

This is a long page number:

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Qualitative Analysis and Consideration of

Trustworthiness

Consent was given by all participants to record the interviews. Interviews were subsequently transcribed ver- batim by the first author (S.B.).

Inductive analytic techniques were used in which the data were used to generate ideas rather than confirm or negate ideas.27 _{The identification of codes from the raw}

data was guided by broad questions such as “what is going on here?” rather than detailed line by line coding.28A list of codes was compiled and refined in an ongoing process of constant comparative analysis throughout the data

analysis.29_{The refined “code book” had a tree-like struc-}

ture that was able to describe all raw data. Coded raw data were entered into a computer program that sorted the extracts by code. For example, all extracts to which the researcher had assigned the code “damage beliefs” were grouped together. This provided an audit trail by which all authors could reflect on the sensitivity of the codes to the meanings and interpretations of the individual participant.30

After each transcript had been coded, main codes were identified. These were the codes considered most relevant to the research question for that individual, reflected by the

TABLE 1. Demographic Data

Code Sex Age Marital Status Occupation TSK Score Duration LBP (y)

010 Male 39 Married Disability pension 42 13

011 Female 39 Married Administration/grocery stockist 65 0.5

012 Female 33 Single Administration 53 12

013 Female 51 Single Nurse 56 2

014 Female 39 Married Relief teacher 42 4

015 Female 25 De Facto Nurse 46 0.5

016 Female 41 Married Construction management 48 0.75

017 Male 42 Married Teacher 50 2

018 Male 54 Single Unemployed 46 6

019 Male 33 Single Air conditioning mechanic 45 8

020 Female 33 Partner Forensic police 46 0.5

022 Female 60 Married Market Research 51 13

024 Female 61 Married Task manager 45 10

025 Female 61 Married Administration 42 0.5

026 Male 49 Single Disability pension 48 20

027 Female 23 Single Physiotherapy student 42 10

028 Male 19 Single Student 47 2

029 Female 53 Single Carer 46 2

030 Female 58 Single Unemployed 46 19

031 Female 27 Single Rigging engineer 42 0.75

032 Female 46 Married Catering company 47 0.75

033 Male 43 Single Unemployed 40 14

036 Female 41 Married Horse trainer 41 7

037 Female 43 Married Unemployed 46 1

038 Female 45 Married Unemployed 40 12

039 Female 38 Divorced Unemployed 46 4

042 Female 45 Divorced Unemployed 55 27

043 Female 47 Single Unemployed 48 2

044 Female 42 Married Part time work 46 11

045 Male 29 Single Unemployed 41 2

046 Male 64 Divorced Small business from home 53 8

047 Female 41 Married Sick leave, administration 53 1

048 Female 39 Separated Unemployed 42 29

049 Female 37 Married Business administration 40 4

050 Male 38 Separated Sick leave, electrician 46 6

052 Male 30 Single Primary school teacher 44 6

TABLE 2. Interview Schedule

Research Question

Themes to

Explore Interview Questions

What does this person believe about their back pain?

Nature of pain Can you put me in your shoes and tell me how your back pain feels? Impact of pain How does your back pain affect your day to day life?

Pain behaviour When you feel the pain in your back, what do you do? Why do you do this? How well do you think you can cope with the pain?

Pain beliefs/object of fear

When you feel the pain in your back, what do you think it is telling you? Why do you think this?

Back beliefs What do you think the function of the spine is? Why?

How is back pain different from other pain you have experienced in the past? Clin J Pain_{Volume 31, Number 7, July 2015 A Mixed Methods Investigation of High TSK Scores}

Copyrightr_{2014 Wolters Kluwer Health, Inc. All rights reserved. www.clinicalpain.com}|623

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. salience of the code to that individual’s experience, rather

than the frequency with which the code occurred. Recurring main codes, emerging themes, were then explored in sub- sequent interviews. This process is exemplified below: 017: If I am hurting, I am probably making a really bad back even worse

S.B.: What makes you think that?

017: Cos it stands for I mean, if something hurts it is for a reason, it is your body saying don’t do it.

In this early interview, “damage beliefs” were consid- ered a key interpretation of the CNSLBP experience in this individual. This belief was explored in sub- sequent interviews, in which it consistently emerged as a main code.

The first author, S.B., coded all raw data and identified main codes for each participant. A random sample of 8 transcripts was analyzed by the coauthors, and the inter- coder consistency of main codes was high. Emerging themes were discussed between authors and challenged through theoretical sampling in which cases of ambiguity and neg- ative cases were specifically sought.29 _{For example, to}

explore the emerging theme “damage beliefs” we recruited and included in this sample 2 nurses and 1 physiotherapist with CNSLBP and high TSK scores who we thought might hold alternative pain beliefs because of a more detailed understanding of pain physiology.

As this study is part of a larger prospective study, scheduled follow-up interviews were conducted with 30 of the participants 4 months after the initial interview. Six participants were not contactable for follow-up. The authors did not consider the experiences reported at base- line by the 6 participants lost to follow-up to differ sub- stantially from those who participated in the follow-up interviews. Follow-up interviews lasted approximately 30 minutes and provided an opportunity for member checking31 of main codes identified for individual partic- ipants and emerging themes across participants.

Once the authors considered the final themes to be representative of the participants’ experience, they were then subjected to a process of interpretation in which they were considered in the context of current understanding from the literature. Two main themes that were identified through this process reflecting the beliefs that: (1) painful activity will result in damage; and (2) painful activity will increase suffering and/or functional loss.

Qualitative Findings

The Belief That Painful Activity Will Result in Damage

Many participants in the study believed pain to be a sign of tissue damage, reflecting the biomedical belief that “hurt” is correlated with pathology. Pain as a danger or harm made sense to them. In words of a participant: “If something hurts, it is for a reason. It is your body saying don’t do it” (017).

Many participants reported reducing activity in response to pain believed to be a sign that damage was occurring to their physical structure:

“I stop because I am basically trying to not do more damage to it, that is what is going through my mind” (038).

“I would never bend over to pick something up. I try to brace myself on any move (y) because any time it hurts I think that I’m doing more damage. Like if it hurts it is getting worse and I am killing, I am breaking down, I am killing myself” (017). This image of disintegration and dying is an

In document Tesis: "Manejo Económico y Ambiental de los Residuos Sólidos Urbanos, Xalapa, Ver ". Alumna: Sara Yvette Montiel Acosta. Director de Tesis: Dr. Gustavo Adolfo Guerra Galindo. Entidad Académica: Facultad de Economía, Universidad Veracruzana. Año: 2013 (página 23-0)