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sychometric Properties of the Fear-Avoidance Beliefsuestionnaire and Tampa Scale of Kinesiophobia

n Patients With Shoulder Painaul E. Mintken, PT, DPT, Joshua A. Cleland, PT, PhD, Julie M. Whitman, PT, DSc,

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ABSTRACT. Mintken PE, Cleland JA, Whitman JM,eorge SZ. Psychometric properties of the Fear-Avoidanceeliefs Questionnaire and Tampa Scale of Kinesiophobia inatients with shoulder pain. Arch Phys Med Rehabil 2010;91:128-36.

Objective: To investigate the reliability and validity of 2ommonly used measures of pain related fear in patients withhoulder pain.

Design: A preplanned secondary analysis of a prospectiveingle-arm trial involving a repeated-measures design.

Setting: Outpatient physical therapy clinics.Participants: Patients (N�80) with a primary report of

houlder pain.Intervention: All patients completed the outcome measures

t baseline and at follow-up.Main Outcome Measures: Patients completed a modified

ear-Avoidance Beliefs Questionnaire (FABQ), the 11-itemersion of Tampa Scale of Kinesiophobia (TSK-11), and thehoulder Pain and Disability Index (SPADI) at baseline and at48-hour follow-up. Patients were dichotomized as improved

r stable at follow-up based on the Global Rating of Change.Results: Factor analysis indicated 3 stable factors for the

ABQ and 1 stable factor for the TSK-11. Shoulder specificcoring for the FABQ and TSK-11 were used in subsequentnalyses. Test-retest reliability intraclass correlation coefficientICC) was substantial for the FABQ and the TSK-11. TheABQ correlated significantly with SPADI pain and disabilitycores, while the TSK-11 correlated significantly only withPADI pain scores. The shoulder-specific FABQ–W (workeliefs subscale) was a better than chance predictor of missingays of work during the 48-hour study period.Conclusions: The modified FABQ and TSK-11 may be

ppropriate for use in patients with shoulder pain. Shoulder-

From the University of Colorado Denver, School of Medicine, Department ofhysical Therapy, Aurora, CO (Mintken); Wardenburg Health Center at the Univer-ity of Colorado Boulder, Boulder, CO (Mintken); Department of Physical Therapy,ranklin Pierce University (Cleland), and Concord Hospital (Cleland), Concord, NH;egis University Manual Therapy Fellowship Program, Denver, CO (Cleland), Evi-ence in Motion’s Orthopedic Manual Physical Therapy Program, Louisville, KYWhitman), School of Physical Therapy, Regis University, Denver, CO (Whitman),epartment of Physical Therapy, Center for Pain Research and Behavioral Health,niversity of Florida, Gainesville, FL (George).Supported by the American Academy of Orthopaedic Manual Physical Therapists

nd Cardon Rehabilitation (grant no. _____).This study is registered at www.clinicaltrials.gov: Identifier: NCT00835302.No commercial party having a direct financial interest in the results of the research

upporting this article has or will confer a benefit on the authors or on any organi-ation with which the authors are associated.

Correspondence to Paul E. Mintken, PT, DPT, University of Colorado Denver,chool of Medicine, Physical Therapy Program, 13121 E 17th Ave, PO Box 6508,urora, CO 80045, e-mail: Paul.mintken@ucdenver.edu. Reprints are not available

rom the author.

0003-9993/10/9107-00897$36.00/0doi:10.1016/j.apmr.2010.04.009

rch Phys Med Rehabil Vol 91, July 2010

pecific scoring of these measures resulted in substantial test-etest reliability, and the FABQ correlated with the SPADI forain and disability. The FABQ also showed potential for pre-iction of short-term work loss in this sample. Pain-related fearay be an important variable in patients with shoulder pain anderits future consideration in longitudinal studies.Key Words: Avoidance learning; Fear; Psychology; Move-ent; Rehabilitation.© 2010 by the American Congress of Rehabilitationedicine

HE POINT PREVALENCE of shoulder symptoms hasbeen reported to range from 20% to 33%,1 and the inci-

ence of shoulder complaints in the general population isncreasing.2 Furthermore, several authors have reported lowates of perceived recovery for patients with a new episode ofhoulder or neck pain.3-6 According to Bot et al,3 less than 25%f patients with a first episode of shoulder pain reported re-overy after 3 months, and only 32% stated they no longer hadymptoms after 1 year. Croft et al4 reported recovery rates ofnly 21% after 6 months and 49% after 18 months. Van derindt et al5 and Winters et al6 reported recovery rates of 51%

nd 59% after 12 to 18 months, respectively. Finally, Rekola etl7 reported that 25% of patients with shoulder or neck painxperienced at least 1 episode of recurrence within 12 months.hese findings suggest that shoulder pain can be recurrent and

requently progresses to the chronic stage.Behavior that is guided by fear has the potential to impact

utcomes negatively for patients with musculoskeletal pain.8-13

ethem et al8 proposed the Fear-Avoidance Model of Exag-

List of Abbreviations

AUC area under the curveCI confidence intervalEFA exploratory factor analysisFABQ Fear-Avoidance Beliefs QuestionnaireFABQ-PA Fear-Avoidance Beliefs Questionnaire Physical

Activity SubscaleFABQ-W Fear-Avoidance Beliefs Questionnaire Work

SubscaleGRC global rating of changeLBP low back painLR likelihood ratioPCA principal components analysisROC receiver operator characteristicSPADI Shoulder Pain and Disability IndexTSK Tampa Scale of KinesiophobiaTSK-11 11-item version of Tampa Scale of

Kinesiophobia

TSK-AA Items 1,2,9,11 of the TSK-11

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1129SHOULDER PAIN AND FEAR AVOIDANCE BELIEFS, Mintken

erated Pain Perception that described the influence fear had onutcomes. They hypothesized that the sensory and emotionalomponent of pain may lead to a fear of pain that may con-ribute to the development of chronic musculoskeletal painyndromes. The complex interaction between the physiologicactors (sensation of pain) and psychologic factors (emotionaleaction to pain) may lead to a maladaptive response in whichhe perception of pain becomes exaggerated.14 Patients with aesynchronous relationship between the physiologic and thesychologic components may attempt to reduce pain symptomsy avoiding physical function, which potentially leads tohronic disability over time.14 Several cross-sectional studiesave shown an association between pain-related fear and dis-bility,15-17 and further research has shown that pain-relatedear may lead to poor clinical outcomes.9-13,18-22

Currently, the evidence supports assessing pain-related fearn patients with LBP,15,16,18,23-28 neck pain,29-35 knee pain,36,37

houlder pain,13,30,34,38-40 and other musculoskeletal condi-ions.11,41-48 Two questionnaires commonly used to measureear of movement and fear-avoidance beliefs in patients withusculoskeletal conditions include the FABQ and theSK.16,29,49 Waddell et al17 originally developed the FABQ,hich consists of a work (FABQ-W) and a physical activity

FABQ-PA) scale. The FABQ has been shown to be a valideasure of fear-avoidance behavior with high test-retest reli-

bility in patients with neck and LBP.23,29,49,50 The originalSK was a 17-item measure that assessed fear of movementnd injury or reinjury.49 Patients rate each item on a 4-pointikert scale with scoring alternatives ranging from “stronglyisagree” to “strongly agree.” Woby et al51 shortened the TSKrom 17 items to 11 items. The TSK-11 had marginally betternternal consistency (��.79) than the TSK, which partiallyupports previous findings that showed removing the 4 in-ersely scored items increased the internal consistency of theSK. Therefore, the TSK-11 possesses similar measurementroperties to the original and offers the advantage of brevity.51

he psychometric properties of the FABQ, TSK-11, and theSK have been well reported in patients with neck pain andBP.17-19,22,29,49,51-55

Pain-related fear has been shown to have a correlation withhoulder disability in several studies.30,34,38-40,56 Lentz et al40

ound that pain-related fear contributed additional variance tohoulder disability in subjects with shoulder-related pathology.eorge et al56 investigated pain-related fear in healthy subjectsho were subjected to a shoulder fatigue protocol. They re-orted that higher fear was predictive of higher levels ofisability, and fear of pain was associated with pain, disability,nd kinesiophobia. Kuijpers et al57 derived a clinical predictionule for shoulder pain-related sick leave and found that theresence of psychologic variables was prognostic for poorutcome in work-related shoulder pain.If pain-related fear is correlated to pain and disability in

atients with shoulder pain, this would give clinicians insightnto potential modifiable factors that may help guide behavioralntervention strategies.40 The purpose of this study was tonvestigate specific psychometric properties of the FABQ andSK-11 in a group of patients with shoulder pain. First, we

eported the factor structure of the FABQ and TSK-11 becausehese data have not been previously reported for patients withhoulder pain. In this process, we developed shoulder-specificcoring for these measures. Second, we investigated test-retesteliability of the shoulder-specific fear measures for patientsho remained stable after receiving intervention. Last, weetermined which specific pain-related fear measure contrib-

ted to reports of pain, disability, and work loss. p

METHODS

ubjectsSubjects included in this preplanned secondary analysis were

onsecutive patients with a primary report of mechanical shoul-er pain referred to physical therapy at 1 of 7 outpatienthysical therapy clinics who agreed to participate in a prospec-ive single-group cohort trial.58 The specific aim of this trialas to investigate the effects of cervicothoracic manipulationn patients with shoulder pain, with a secondary aim of inves-igating the presence of fear-avoidance beliefs in this popula-ion. Inclusion criteria for the cohort trial included patient ageetween 18 and 65 years with a primary complaint of shoulderain and a baseline SPADI59 score of 20% or greater. Exclu-ion criteria included any medical red flags suggestive ofonmusculoskeletal disorders, acute fractures in the shoulderegion, acute severe trauma in the cervical or thoracic region inhe last 6 weeks, a diagnosis of cervical spinal stenosis orilateral upper-extremity symptoms, osteoporosis, prior sur-ery to the cervical or thoracic region, evidence of centralervous system involvement, insufficient English languagekills to complete the questionnaires, or signs consistent witherve root compression (defined as impairment in at least 2 ofhe following: reflexes, myotomal strength, or sensation). Allubjects reviewed and signed a consent form approved by 1 ofhe following institutional review boards: the University ofolorado at Boulder, Boulder, CO; the University of Coloradoenver, Aurora, CO; Regis University, Denver, CO; Newtonellesley Hospital, Newton, MA; or Concord Hospital, Con-

ord, NH.

easurement and ProceduresA single-group repeated measures design was used to inves-

igate the psychometric properties of the FABQ and TSK-11.t the initial session, all patients provided demographic infor-ation and completed a variety of self-report measures, fol-

owed by a standardized history and physical examination.elf-report measures included the numerical pain rating scale,60

he SPADI,59 the FABQ, and the TSK-11. The SPADI was usedo capture the patient’s perceived level of disability as a resultf shoulder pain.59 The SPADI is a 13-item questionnaireonsisting of a pain subscale with 5 questions and a disabilityubscale with 8. The SPADI is a well investigated outcomeeasure and has demonstrated reliability and validity in as-

essing shoulder pain and disability. The validity and respon-iveness to change of SPADI have been described in physicalherapy as well as primary and secondary care settings.61

oach et al61 determined the reliability of the SPADI throughalculation of internal consistency values, with Cronbach alphaalues ranging from .86 to .95. Beaton and Richards62 reportedhat the individual-level reliability of measurements obtainedith the SPADI had an ICC of .91. The minimal clinically

mportant difference is 10 points.63 Williams et al63 also foundmoderate correlation between the SPADI and the physical

unction and pain components of the Medical Outcomes Study0-Item Short-Form Health Survey, thus supporting the con-truct validity of the SPADI. Based on the psychometric prop-rties of the SPADI, Roddey et al64 have supported the use ofhe SPADI as a superior region-specific outcomes tool foratient with shoulder disorders.In patients with LBP, the FABQ consists of 2 scales: the

-item FABQ-PA and the 7-item FABQ-W subscale.17 Eachtem is scored from 0 to 6, with higher scores representingreater levels of fear-avoidance behavior. In patients with LBP,

ossible scores range from 0 to 24 and 0 to 42 for the

Arch Phys Med Rehabil Vol 91, July 2010

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ABQ-PA and FABQ-W scales, respectively. In this study, thendividual items of the FABQ were modified to replace theord “back” with “shoulder,” and we determined shoulder-

pecific scoring of FABQ scales based on factor analysis re-ults.

The TSK is not a region-specific measure and has applica-ion to a variety of musculoskeletal pain conditions. The TSKas been used in various forms, originally including 17 itemsurported to identify the fear of movement or rein-ury.29,51,54,65,66 Swinkels-Meewisse et al49 reported that ahortened version of the TSK exhibited a stronger correlationith the FABQ-W scale than the 17-item questionnaire inatients with LBP. This questionnaire was further shortened to1 items by Woby.51 The 11-item scale was used in the currenttudy (TSK-11). Each question is scored on a 4-point Likertcale with 1 indicating “strongly disagree” and 4 indicatingstrongly agree.” Total scores range from 11 to 44, with highercores representing increased fear of movement. We deter-ined shoulder-specific scoring of the TSK-11 based on factor

nalysis results.On completion of the self-report measures, each patient

nderwent a standardized history and physical examination.he specific aim of the trial was to investigate the effects ofervicothoracic manipulation on patients with shoulder pain,58

ith a secondary aim of investigating psychometric propertiesor pain-related fear measures in this population. Once thexamination was complete, all patients received treatment con-isting of spinal manipulation to the cervicothoracic spine andactive range-of-motion exercises. Patients were then sched-

led for a follow-up session within 2 to 4 days of the baselinexamination. At the start of the second session, all subjectsgain completed the self-report measures including the FABQnd TSK-11, as well as the GRC as described by Jaeschke etl.67 Patients were asked to rate their perception of changeince the start of treatment on a scale ranging from –7 (a veryreat deal worse) to 0 (about the same) to �7 (a very great dealetter). It has been reported67 that scores on the GRC between3 and �1 represent little to no change, scores between �4

nd �5 represent moderate changes, and scores of �6 or �7epresent large changes. Similar to other studies,68-70 patientsere categorized as stable if they scored between a –3 and �3n the GRC.

ata AnalysisEFA with PCA and orthogonal (ie, Varimax) rotation with

aiser normalization was completed on the FABQ and TSK toescribe factor solutions for patients with shoulder pain. TheABQ and TSK-11 are established measures, but we selectedFA for this analysis. EFA was appropriate because FABQ andSK-11 factor structures have not been reported for patientsith shoulder pain and we did not have a priori hypotheses

bout their factor structure in this population. Furthermore,FA was an appropriate selection for this sample size becauseaximum likelihood–based estimates (eg, confirmatory factor

nalysis) are unbiased only for very large sample sizes. Or-hogonal factor solutions were imposed on the FABQ becausehat is consistent with the original analysis for patients withBP.17 The original analysis for the TSK is not as clear, but

here are clear precedents in the literature for use of orthogonalactor solutions for the original 17-item TSK.71,72 An explor-tory investigation of oblique rotation (ie, Oblimin) was per-ormed because correlations might be expected for differentear factors, and these factor solutions were compared with therthogonal solutions. Overall, this analytic approach is very

onsistent with the original FABQ analysis17 and a recent (

rch Phys Med Rehabil Vol 91, July 2010

nvestigation of the original TSK factor structure for patientsith fibromyalgia.71

Factors extracted from the PCA were given further consid-ration if they were associated with eigenvalues greater than.0. Individual items were evaluated using guidelines from anarlier investigation of the Multidimensional Pain Inventory.73

pecifically, items with highest loading on each factor wereetained unless the absolute item loading was less than .50. Antem that loaded on 2 factors and had an absolute difference inoading less than .25 was further investigated for its appropriateactor. Factors were then evaluated based on cumulative re-ponse variance and internal consistency. Specifically, the vari-nce accounted for by all factors needed to be greater than0%, and the internal consistency of a given factor needed toe greater than .70. Overall, the consideration of items andactors was also very consistent with the recent investigation ofSK factor structure for patients with fibromyalgia.71 Final

actor solutions for the FABQ and TSK-11 were used forhoulder-specific scoring of these measures in subsequent anal-ses (unweighted by factor score).Descriptive statistics were then generated for the entire sam-

le in the appropriate metric for continuous and categoricariables. Sex differences were investigated with independenttests for FABQ and TSK-11 because previous reports have

ndicated sex differences in pain-related fear measures. Patientsere dichotomized into acute (�90d or less) and chronic (�90d)

houlder symptoms, and differences in symptom duration werelso investigated by independent t test for FABQ and TSK-11ecause acuity has been reported to influence pain-related feareasures. All data reported in this article were from the first

reatment session except for the test-retest data, which includedata from the second treatment session.For the test-retest reliability, patients were dichotomized intogroups based on the GRC. Patients scoring between –3 and3 on the GRC were considered stable (minimal to no

hange).67 Test-retest reliability of the FABQ and TSK-11 wasnvestigated in the group of stable patients using an ICC2,1 withhe 95% CIs calculated according to procedures described byhrout and Fleiss.74 The test-retest reliability interval wasetween the first and second treatment sessions. Only patientsho rated their GRC as stable (n�42) during this interval weresed for the reliability analysis. The GRC is frequently used tovaluate the reliability of self-report questionnaires.69, 75-78

Concurrent validity was assessed by reporting correlationsPearson r) of the TSK-11 and FABQ with the SPADI pain,PADI disability, and SPADI total outcome measure. Concur-ent validity was further assessed by separate multiple regres-ion models. These models determined whether FABQ orSK-11 contributed additional variance to the dependent vari-bles of SPADI pain and disability scores. The independentariables for these regression analyses were sex, age, andymptom duration followed by the FABQ and TSK-11. Thesenalyses would provide information on which particular pain-elated fear measure was associated with the SPADI, a com-only used outcome measure for patients with shoulder pain.ull and reduced (ie, stepwise consideration of all variables andeporting only those having reliable association with dependentariable) multiple regression models were reported.An exploratory analysis was planned to investigate only

ain-related fear measures that demonstrated reliable associa-ion with SPADI pain and disability scores in the aforemen-ioned regression analyses. ROC curves were generated toetermine whether the appropriate fear measure could predictissing work during the 48-hour study period. ROC curves are

raphic depiction of sensitivity (y-axis) against 1 – specificity

x-axis) used to quantify the predictive performance of mea-

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1131SHOULDER PAIN AND FEAR AVOIDANCE BELIEFS, Mintken

ures. One way the predictive performance can be quantified isalculating AUC; an AUC of 1.0 represents prefect prediction,hile an AUC of .50 represents chance prediction. In this

tudy, AUC was reported with a 95% CI to determine whetherhe fear measure had better than chance predictive ability foretermining missing any days of work (ie, to determinehether the lower bound contained .50). If a fear measure hadetter than chance predictive ability, a range of positive andegative likelihood ratios (�LR and –LR) was reported torovide a preliminary indication of potential cutoff scores. Inhis analysis, a �LR would indicate the true-positive to false-ositive rate (ie, ruling in) for a particular fear score beingredictive of a patient missing work, while a –LR wouldndicate the false-negative to true-negative rate (ie, ruling out)or a particular fear score being predictive of a patient notissing work.

RESULTSEighty consecutive patients with shoulder pain were enrolled

n the study. PCA for the FABQ identified a 4-factor solutionith a cumulative response variance of 73.5% (table 1). Eig-

nvalues of the individual factors were 5.8 (36.0% variance),.5 (15.9%), 2.2 (13.5%), and 1.3 (8.1%), respectively. Itemsoading less than .50 were not retained on the individualactors, so item loading ranged from .52 to .90 after orthogonalotation with 2 items cross-loaded (2 and 12). In the explor-tory analysis with oblique rotation, an identical factor struc-ure was produced, and the factors were not strongly correlatedith each other (maximum r�.28). Therefore, only the orthog-nal solution was reported in this article, consistent with theriginal FABQ analysis for patients with LBP.17

Further analysis indicated the fourth factor (physical activityain beliefs) did not meet reliability criterion, so this factor wasegarded as unstable. Cross-loading was noted for FABQ itemsand 12. The difference in loading did not exceed .25, so these

Table 1: FABQ Factor Solution for Patients With Shoulder Pain

FactorsWork Pain

BeliefsConsequences

of Work

Consequencesof Physical

Activity

PhysicalActivity Pain

Beliefs

Eigenvalue 5.8 2.5 2.2 1.3% of variance 36.0 15.9 13.5 8.1Cronbach � .89 .88 .74 .59FABQ 1 .912FABQ 2 .658 .526

FABQ 3 .779FABQ 4 .771FABQ 5 .732FABQ 6 .718FABQ 7 .890FABQ 8 .626FABQ 9 .648FABQ 10 .900FABQ 11 .832FABQ 12 .620 .523

FABQ 13 .820FABQ 14 .896FABQ 15 .877FABQ 16 .869

OTE. Extraction method: PCA. Rotation method: Varimax with Kai-er normalization (rotation converged in 6 iterations). Items withoadings of less than .50 were suppressed from the table for ease ofnterpretation. Cross-loaded items are shown in boldface.

tems were further investigated for inclusion on a specificNF

actor. Item 12 had its highest loading on the work pain beliefsactor, and its exclusion did not improve the reliability ofhis factor. Therefore, item 12 was retained on the work paineliefs factor. Item 2 had its highest loading on the conse-uences of physical activity factor, and its exclusion did notmprove reliability of this factor. Therefore, item 2 was re-ained on the physical activity factor. These analyses suggesthat the FABQ consisted of 3 stable factors for patients withhoulder pain including “work pain beliefs” (items 8, 9, 12, 13,4, 15, and 16), “consequences of work,” (Items 6, 7, 10, and1), and “consequences of physical activity” (Items 2, 3, 4, and). These scales were scored (unweighted) and referred to ashe FABQ-WB, FABQ-WC, and FABQ-PA, respectively, forubsequent analyses.

PCA for the TSK-11 identified a 4-factor solution with aumulative response variance of 66.1% (table 2). Eigenvaluesf the individual factors were 3.5 (31.8% variance), 1.413.0%), 1.2 (11.2%), and 1.1 (10.1%), respectively. Itemsoading less than .50 were not retained on the individual

Table 2: Exploratory Factor Solution for TSK-11 for Subjects WithShoulder Pain

Factors

ActivityAvoidance

Because of Pain

PainIndicates

Injury

ActivityAvoidanceBecause of

Threat

Credibilityof

Complaints

Eigenvalue 3.5 1.4 1.2 1.1% of variance 31.8 13.0 11.2 10.1Cronbach � .72 .69 .29TSK 1 .875TSK 2 .710TSK 3 .520TSK 4 .807TSK 5 .824TSK 6 .852TSK 7 .692TSK 8 .658TSK 9 .668TSK 10 .550TSK 11 .593

OTE. Extraction method: PCA. Rotation method: Varimax with Kai-er Normalization (rotation converged in 7 iterations). Items withoadings of less than .50 were suppressed from the table for ease ofnterpretation.

Table 3: Baseline Characteristics of Subjects With Shoulder Pain

VariableAll Subjects

(n � 80)

Age (y), mean � SD 41.2 � 13.2Sex: female, n (%) 48 (60)Days since onset, mean � SD 511.0 � 1502.7Symptoms greater than 90 days, n (%) 52 (65)SPADI Pain, mean � SD 50.8 � 15.9SPADI Disability, mean � SD 29.2 � 15.7Missed work as a result of shoulder

pain: yes, n (%)9 (11.25)

FABQ-PA 9.7 (4.2)FABQ-WB 3.4 (6.5)FABQ-WC 8.0 (7.2)TSK-AA 9.1 (2.5)

OTE. Values are mean � SD or numbers and percentages. For FABQ-PA,ABQ-WB, FABQ-WC, and TSK-AA, shoulder-specific scoring.

Arch Phys Med Rehabil Vol 91, July 2010

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1132 SHOULDER PAIN AND FEAR AVOIDANCE BELIEFS, Mintken

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actors, so item loading ranged from .52 to .88 after orthogonalotation with no cross-loading noted. In the exploratory anal-sis with oblique rotation, there were very few differences inhe factor loading, and the factors were not strongly correlatedith each other (maximum r�.31). Therefore, only the orthog-nal solution was reported in this article, consistent with aecent TSK analysis for patients with fibromyalgia.71

Further analysis of the factor solution indicated 3 of the 4actors did not meet the reliability criterion (pain indicatesnjury and activity avoidance because of threat), or reliabilityould not be assessed (credibility of complaints). These factorsere not further considered. These analyses suggest that theSK-11 consisted of 1 stable factor for patients with shoulderain consisting of “activity avoidance due to pain” (items 1, 2,, 11). This scale was scored (unweighted) and is referred to ashe TSK-AA in subsequent analyses.

Descriptive statistics for baseline measures, including SDs,re reported in Table 3. The sexes reported similar mean scores

SD (P�.05) for FABQ-PA (men, 10.4�4.3, vs women,.1�4.1), FABQ-WB (men, 3.3�7.5, vs women, 3.4�5.9),ABQ-WC (men, 6.7�7.4, vs women, 8.8�7.0), and TSK-AAmen, 9.2�2.7, vs women, 9.1�2.4). Duration was associatedith similar mean scores � SD (P�.05) for the FABQ-PA

acute, 9.1�3.9, vs chronic, 9.9�4.4) and TSK (acute,.2�1.9, vs, chronic, 9.1�2.8). However, higher scores weressociated with chronic symptoms (P�.05) in this sample forhe FABQ-WB (acute, 1.4�2.7, vs chronic, 4.4�7.7) andABQ-WC (acute, 5.1�6.4, vs chronic, 9.6�7.1) scales.The test-retest reliability coefficient for the FABQ-PA was

88 (95% CI, .75–.93); the FABQ-WB, .98 (95% CI, .96–.99);he FABQ-WC, .94 (95% CI, .86–.97); and the TSK-AA, .8495% CI, .69–.91). Pearson correlations for the shoulder-pecific measures are reported in table 4. The FABQ-PA andABQ-WB were significantly correlated with SPADI pain andisability, while the FABQ-WC was not correlated with either.he TSK-AA was correlated only with SPADI pain.Full and reduced regression models for the SPADI outcomeeasure are reported in tables 5 and 6. In the full model for

ain, the 7 variables contributed moderate variance to SPADIain scores (R2�.19; P�.01). The FABQ-WB was identified ashe strongest individual contributor in the full model, and in theeduced model, it alone accounted for 14% of the variance inPADI pain scores (P�.01). No other variables were retained

n the reduced model for pain.In the full model for disability, the 7 variables contributedinimal variance to SPADI disability scores (R2�.18; P�.01).he FABQ-PA was identified as the strongest individual con-

ributor to this model, and in the reduced model, it aloneccounted for 11% of the variance in SPADI disability scoresP�.01). No other variables were retained in the reduced

Table 4: Pearson Correlations for Pain-Related Fear Measures andShoulder Pain and Disability

SPADIDisability FABQ-PA FABQ-WB FABQ-WC TSK-AA

SPADI Pain .504† .224* .364† .166 .272*SPADI Disability .323† .255* .046 .268FABQ-PA .221 .217 .553†

FABQ-WB .438† .281*FABQ-WC �.005

OTE. For FABQ-PA, FABQ-WB, FABQ-WC, and TSK-AA, shoulder-pecific scoring.Correlation is significant at the .05 level (2-tailed).Correlation is significant at the .01 level (2-tailed).

odel for disability.Sa

rch Phys Med Rehabil Vol 91, July 2010

During the study period, 9 (11.3%) of 80 reported missingny work days because of shoulder pain. Based on theesults of the regression analyses, the shoulder-specificABQ-PA and FABQ-WB measures were considered forredictors of missing days of work over the 48-hour studyeriod. The FABQ-PA had an AUC of .57 (95% CI, .34 –81), while the FABQ-WB had an AUC of .75 (95% CI,54 –.96). Only the FABQ-WB had better than chance pre-iction of missing work, and the appropriate evaluativeetrics were calculated (table 7). The �LR indicated that

ncreased risk for missing work, especially for elevatedABQ-WB scores, exceeded 8. The –LR indicated that riskor returning to work was not strongly predicted by lowerABQ-WB scores.

Table 5: Regression Models for Pain-Related Fear Measures andShoulder Pain

Predictor Variables �Partial

Correlation P Value

Dependent Variable � SPADI Pain(R2 �.19 and P�.01)

(Full Model)Age .09 .09 .47Sex .09 .09 .46Symptom duration –.09 –.09 .46FABQ-PA .09 .08 .51FABQ-WB .33 .29 .02FABQ-WC .01 .01 .91TSK-AA .13 .11 .36

Dependent Variable � SPADI Pain(R2�.14 and P�.01)

(Reduced Model)FABQ-WB .37 .37 �.01

OTE. For FABQ-PA, FABQ-WB, FABQ-WC, and TSK-AA, shoulder-pecific scoring.ex coded as 0, male; 1, female. Symptom duration coded as 0,cute; 1, chronic.

Table 6: Regression Models for Pain-Related Fear Measures andShoulder Disability

Predictor Variables �Partial

Correlation P Value

Dependent Variable � SPADI Disability(R2�.18 and P�.01)

(Full Model)Age .09 .09 .44Sex .02 .02 .85Symptom duration –.13 –.13 .30FABQ-PA .27 .23 .06FABQ-WB .24 .21 .08FABQ-WC –.07 –.06 .61TSK-AA .05 .05 .71

Dependent Variable � SPADI Disability(R2�.11 and P�.01)

(Reduced Model)FABQ-PA .33 .33 �.01

OTE. For FABQ-PA, FABQ-WB, FABQ-WC, and TSK-AA, shoulder-pecific scoring.

ex coded as 0, male; 1, female. Symptom duration coded as 0,cute; 1, chronic.

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1133SHOULDER PAIN AND FEAR AVOIDANCE BELIEFS, Mintken

DISCUSSIONCurrent evidence demonstrates that a large percentage of

atients with shoulder pain will progress to chronicity, and thisroup will be responsible for a significant proportion of theealth care costs for this condition.79-81 Fear-avoidance behav-ors have been identified as contributing to the development ofhronic symptoms in patients with musculoskeletal disor-ers.18,19,32,33,82-84 Pain-related fear plays a role in shoulderisability.30,34,38-40,56 We believe that this study adds to thevidence that the Fear-Avoidance Model of Exaggerated Painerception may have broad application in musculoskeletalain. The major implications of the current study are that theABQ may be appropriate in assessing pain-related fear inatients with shoulder pain. Specifically, this analysis providesreliminary support for the assessment of pain-related fear inhoulder pain by reporting factor structure and shoulder spe-ific scoring for the FABQ and TSK-11. This study alsonvestigated the test-retest reliability and concurrent validity ofhese measures in a cohort of patients with a primary report ofhoulder pain. The test-retest reliability was substantial for thehoulder-specific FABQ and TSK scales. The shoulder-specificABQ was associated with pain, disability, and short-termork loss. Therefore, the FABQ, especially the FABQ-WB,ay serve as a useful screening tool that might allow the

linician to implement treatment strategies known to improveutcomes in patients with fear-avoidance behaviors.85-87

The shoulder specific FABQ and TSK had factor solutionshat differed slightly from what has been previously reported inhe literature for those with other pain condi-ions,29,49,51,53,54,82,88-91 but overall encompassed very similaromains for patients with shoulder pain. For example, theABQ was largely constituted of beliefs related to work andhysical activity in our sample, which matches previous re-orts. The TSK differed more for patients in shoulder pain inhat there was only 1 stable factor, and it was related to activityvoidance. Other authors have reported a somatic focus factoror the TSK, but we did not detect a stable factor related toomatic focus for patients with shoulder pain. The inconsisten-ies for the TSK are not new, because solutions involving 1, 2,nd 4 factors have been reported for the TSK.71 Our datauggest that only a single 4-item factor is appropriate for thoseith shoulder pain, which was very similar to the recommen-

Table 7: Missing Work Prediction Metrics for Shoulder-SpecificFABQ-WB

FABQ-WB Score Sensitivity Specificity �LR –LR

0.5000 .75 .58 1.81 .421.5000 .75 .63 2.02 .402.5000 .62 .70 2.08 .553.5000 .62 .77 2.73 .495.0000 .62 .83 3.65 .456.5000 .50 .84 3.18 .597.5000 .50 .87 3.89 .578.5000 .50 .90 5.00 .569.5000 .50 .91 5.83 .55

10.5000 .37 .94 6.56 .6612.5000 .37 .95 8.75 .6514.5000 .37 .97 13.13 .6416.5000 .25 .99 17.5 .76

OTE. Dependent variable for the prediction, missed work during8-hour study period. FABQ-WB, shoulder-specific scoring. AUC forOC curve � .75 (95%, confidence interval, .54–.96).

ation for patients with fibromyalgia.71 These factor solutions h

re only preliminary, and future studies in larger, independentamples are necessary to confirm the factor structure of theABQ and TSK for patients with shoulder pain.In addition to a better factor structure, the FABQ was more

trongly associated with SPADI in comparison with the TSK.oth the FABQ-PA and FABQ-WB were related to SPADI painnd disability scores. The TSK-AA was related only to SPADIain scores, not disability. Similarly, studies in other patient pop-lations have demonstrated that the original TSK may not corre-ate with disability.29,30,54,92 These associations were evident inhe 0 order correlation matrix and in multiple regression modelshat controlled for age, sex, and duration of symptoms.

Because of the short follow-up, we were not able truly to assesshe long-term predictive validity of the FABQ in patients withhoulder pain. However, the FABQ-WB did predict work lossuring the 48-hour study period, and the �LRs generated indicatepotential for identifying those with increased risk of work loss

ased on elevated scores. It is important when interpreting theork loss analysis to consider that we had a relatively small

ample size, short follow-up time, and low distribution (11%) ofhose with work loss. The predictive ability of the FABQ-WBay have been affected by any 1 of these factors, and future

nalysis may consider optimal classification tree analysis proce-ures, especially if larger sample sizes continue to have lowistributions of patients with work loss.

Correlations existed between the shoulder specific measures.he TSK-AA, FABQ-PA, FABQ-WB, and FABQ-WC had as-ociations that were fair in magnitude, which is consistent withtudies in the LBP literature.16,49 This supports the conclusion ofwinkels-Meewisse49 that the measurements of fear-avoidanceeliefs about work and physical activities (FABQ) may be con-tructs separate from kinesiophobia (original TSK). It was inter-sting to note that the TSK-11 was not significantly related toPADI scores, but it was correlated with the FABQ-PA andABQ-W.FABQ-PA scores have been identified as a predictor of disabil-

ty and have also been shown to be significantly correlated withoth pain intensity and disability in patients with LBP.19,93 Ouresults suggest weaker relationships between measures of fear-voidance beliefs and pain and disability among patients withhoulder pain than have been reported among patients with LBP.his finding may be related to the fact that the FABQ wasriginally developed for patients with LBP, and this questionnaireay not adequately capture fear-avoidance beliefs in patients with

houlder pain. Although we changed the term “back” to “shoul-er” in the FABQ, the questionnaire itself may not adequatelyapture fear-avoidance beliefs in patients with shoulder pain.owever, our results suggest the FABQ is superior to the TSK-11

n this patient population.Although more research is required, our results suggest that

ear-avoidance beliefs may be an important variable to consider inuture research examining the development of chronic pain andisability among patients with shoulder pain. It may be that manyf the factors significant in patients with LBP may also play a rolen patients with shoulder pain. The FABQ may have a role inecondary prevention85,94,95 for patients with shoulder pain be-ause it could potentially be used for screening of patients likelyo miss work and/or progress to chronic symptoms.

tudy LimitationsLimitations of this study include that the results of this study

an only be generalized to patients with shoulder pain andannot be applied to patients with other musculoskeletal con-itions. Another limitation is the short-term nature of the workoss variable because it only involved monitoring over 48

ours. Also, using the GRC as the reference standard to deter-

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1134 SHOULDER PAIN AND FEAR AVOIDANCE BELIEFS, Mintken

A

ine improved or stable patients may be considered a limita-ion despite the fact this is commonly done.96-102 The originalrospective study we conducted58 included a preplanned sec-ndary analysis of this data, but some would argue that ourethodology for examining test-retest reliability could have

een improved. Finally, it should be recognized that the studyncluded patients with acute, subacute, and chronic symptoms,hich could have ultimately affected the results. It is possible

hat the results could have differed if only acute or chronicatients were selected.

CONCLUSIONSThe results of the current study support the measurement of

ain-related fear in shoulder pain using a modified FABQ overhe TSK-11. We presented shoulder-specific factor solutionsnd scoring of these measures. Our findings provide additionalvidence that pain-related fear should be considered whenssessing patients with shoulder pain. Although definitive con-lusions cannot be made from these data, FABQ demonstratedn association with shoulder pain and disability in comparisonith the TSK-11. Additionally, the FABQ-WB showed poten-

ial for predictive validity in determining short-term work loss.uture longitudinal studies are needed to investigate further theole fear-avoidance beliefs play in the development of chronichoulder pain.

Acknowledgments: We thank Kristin Carpenter, PT, DPT, Mela-ie Bieniek, PT, DPT, Scott Burns, PT, DPT, Mike Keirns, PT, PhD,my Garrigues, PT, DPT, Paul Glynn, PT, DPT, John Groves, PT,PT, Tim Mondale, PT, DPT, and Emilio “Louie” Puentedura, PT,PT, for their assistance with data collection.

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