Physical activity and the mediating effect of fear, depression, anxiety, and catastrophizing on pain related disability in people with chronic low back pain

Paul W M Marshall, Siobhan Schabrun, Michael F Knox, Paul W M Marshall, Siobhan Schabrun, Michael F Knox

Abstract

Background: Chronic low back pain is a worldwide burden that is not being abated with our current knowledge and treatment of the condition. The fear-avoidance model is used to explain the relationship between pain and disability in patients with chronic low back pain. However there are gaps in empirical support for pathways proposed within this model, and no evidence exists as to whether physical activity moderates these pathways.

Methods: This was a cross-sectional study of 218 people with chronic low back pain. Multiple mediation analyses were conducted to determine the role of fear, catastrophizing, depression, and anxiety in the relationship between pain and disability. Separate analyses were performed with physical activity as the moderator. Individuals were classified as performing regular structured physical activity if they described on average once per week for > 30-minutes an activity classified at least moderate intensity (≥ 4-6 METs), activity prescribed by an allied health professional for their back pain, leisure time sport or recreation, or self-directed physical activity such as resistance exercise.

Results: Fear, catastrophizing, and depression significantly mediated the relationship between pain and disability (p<0.001). However the mediating effect of catastrophizing was conditional upon weekly physical activity. That is, the indirect effect for catastrophizing mediating the relationship between pain and disability was only significant for individuals reporting weekly physical activity (B = 1.31, 95% CI 0.44 to 2.23), compared to individuals reporting no weekly physical activity (B = 0.21, 95% CI -0.50 to 0.97). Catastrophizing also mediated the relationship between pain and fear (B = 0.37, 95% CI 0.15 to 0.62), with higher scores explaining 53% of the total effect of pain on fear.

Conclusions: These results support previous findings about the importance of fear and depression as factors that should be targeted in low back pain patients to reduce back pain related disability. We have also extended understanding for the mediating effect of catastrophizing on back pain related disability. Back pain patients engaged with regular physical activity may require counselling with regards to negative pain perceptions.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. Example of the mediation-moderation model…
Fig 1. Example of the mediation-moderation model tested in this study.
(A) is the primary relationship between pain and disability, with the total effect labelled c. (B) are the proposed mechanisms of mediation and moderation. The direct effect (c’) is the effect of pain on disability after controlling for the mediator variables. The indirect effect of pain on the mediators are the ‘a pathways’. The indirect effect of the mediators on disability are the ‘b pathways’.
Fig 2. Mediation of the relationship between…
Fig 2. Mediation of the relationship between pain and fear through catastrophizing.
Coefficients for the different pathways (a, b, c) are displayed. The indirect effect (a x b pathway) for PCS was 0.37 (95% CI 0.15 to 0.62). *** is p

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