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Neural Correlates Differ in High and Low Fear-Avoidant Chronic Low Back Pain Patients When Imagining Back-Straining Movements

      Highlights

      • High and low fear-avoidant chronic low back pain (CLBP) patients were examined.
      • CLBP patients imagined back-straining activities during functional magnetic resonance imaging.
      • High versus low fear-avoidant CLBP patients showed stronger hippocampus activations.
      • High fear-avoidant CLPB patients versus pain-free control subjects did not differ.

      Abstract

      The fear-avoidance model postulates that in an initial acute phase chronic low back pain (CLBP) patients acquire a fear of movement that results in avoidance of physical activity and contributes to the pain becoming chronic. The current functional magnetic resonance imaging study investigated the neural correlates of imagining back-straining and neutral movements in CLBP patients with high (HFA) and low fear avoidance (LFA) and healthy pain-free participants. Ninety-three persons (62 CLBP patients, 31 healthy controls; age 49.7 ± 9.2 years) participated. The CLBP patients were divided into an HFA and an LFA group using the Tampa Scale of Kinesiophobia. The participants viewed pictures of back-straining and neutral movements and were instructed to imagine that they themselves were executing the activity shown. When imagining back-straining movements, HFA patients as well as healthy controls showed stronger anterior hippocampus activity than LFA patients. The neural activations of HFA patients did not differ from those of healthy controls. This may indicate that imagining back-straining movements triggered pain-related evaluations in healthy controls and HFA participants, but not in LFA participants. Although heightened pain expectancy in HFA compared with LFA patients fits well with the fear-avoidance model, the difference between healthy controls and LFA patients was unexpected and contrary to the fear-avoidance model. Possibly, negative evaluations of the back-straining movements are common but the LFA patients use some kind of strategy enabling them to react differently to the back-straining events.

      Perspective

      It appears that low fear-avoidant back pain patients use some kind of strategy or underlying mechanism that enables them to react with less fear in the face of potentially painful movements. This warrants further investigation because countering fear and avoidance provide an important advantage with respect to disability.

      Key words

      The fear-avoidance model (FA model) is the leading explanation for the transition from acute low back pain to chronic back pain.
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      Fear-avoidance model of chronic pain: The next generation.
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      Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art.
      According to the FA model, in the acute phase, the person acquires a fear of movement
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      • Henderson I.
      • Somerville D.
      • Main C.J.
      A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability.
      or ‘kinesiophobia’
      • Kori S.
      • Miller R.
      • Todd D.
      Kinesiophobia: A new view of chronic pain behavior.
      and as a consequence begins to avoid physical activity. In the long-term, the reduced activity results in musculoskeletal deconditioning
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      • Norton G.R.
      Beyond pain: The role of fear and avoidance in chronicity.
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      • Crombez G.
      • Boersma K.
      • Vlaeyen J.W.
      The Fear-Avoidance Model of musculoskeletal pain: Current state of scientific evidence.
      • Vlaeyen J.W.
      • Linton S.J.
      Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art.
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      • Somerville D.
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      A fear-avoidance beliefs questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability.
      and may culminate in a vicious cycle characterized by pain → catastrophizing → fear of movement/hypervigilance → avoidance of movement → pain sensitization → pain.
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      Fear-avoidance model of chronic pain: The next generation.
      This behavioral pattern may lead to increasing disability and, if the avoidance is extended to various areas of life, can give rise to generalized withdrawal and abet the development of a depressive syndrome.
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      Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art.
      The FA model also received support for other musculoskeletal conditions, such as knee pain,
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      Changes in catastrophizing and kinesiophobia are predictive of changes in disability and pain after treatment in patients with anterior knee pain.
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      Predictors of pain and function outcome after rehabilitation in patients with patellofemoral pain syndrome.
      neck pain,
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      The use of fear-avoidance beliefs and nonorganic signs in predicting prolonged disability in patients with neck pain.
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      The role of fear-avoidance beliefs in patients with neck pain: Relationships with current and future disability and work capacity.
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      Predictive value of fear avoidance in developing chronic neck pain disability: Consequences for clinical decision making.
      and fibromyalgia.
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      Fear of movement and avoidance behaviour toward physical activity in chronic-fatigue syndrome and fibromyalgia: State of the art and implications for clinical practice.
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      Prevalence of fear of pain and activity in patients with fibromyalgia syndrome.
      In the past decade, the FA model has generated a large amount of research activity, accruing evidence that supports the model with regard to chronic low back pain (CLBP)
      • Crombez G.
      • Eccleston C.
      • Van Damme S.
      • Vlaeyen J.W.
      • Karoly P.
      Fear-avoidance model of chronic pain: The next generation.
      : persons with a strong fear of movement expected more pain
      • Crombez G.
      • Eccleston C.
      • Vlaeyen J.W.
      • Vansteenwegen D.
      • Lysens R.
      • Eelen P.
      Exposure to physical movement in low back pain patients: Restricted effects of generalization.
      • Trost Z.
      • France C.R.
      • Thomas J.S.
      Examination of the photograph series of daily activities (PHODA) scale in chronic low back pain patients with high and low kinesiophobia.
      • Trost Z.
      • France C.R.
      • Thomas J.S.
      Exposure to movement in chronic back pain: Evidence of successful generalization across a reaching task.
      and showed distinct physiological patterns
      • Glombiewski J.A.
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      • König S.
      • Lachnit H.
      • Seifart U.
      Do patients with chronic pain show autonomic arousal when confronted with feared movements? An experimental investigation of the fear–avoidance model.
      when they anticipated back-stressing movements, they performed less well in movement tasks than patients with low fear-avoidance (LFA),
      • Crombez G.
      • Vlaeyen J.W.
      • Heuts P.H.
      • Lysens R.
      Pain-related fear is more disabling than pain itself: Evidence on the role of pain-related fear in chronic back pain disability.
      • Geisser M.E.
      • Haig A.J.
      • Theisen M.E.
      Activity avoidance and function in persons with chronic back pain.
      • Mannion A.F.
      • O’Riordan D.
      • Masharawi Y.
      The relationship between psychological factors and performance on the Biering-Sørensen back muscle endurance test.
      • Vlaeyen J.W.
      • Kole-Snijders A.M.
      • Boeren R.G.
      • van Eek H.
      Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance.
      and reported more disability.
      • Crombez G.
      • Vlaeyen J.W.
      • Heuts P.H.
      • Lysens R.
      Pain-related fear is more disabling than pain itself: Evidence on the role of pain-related fear in chronic back pain disability.
      • Peters M.L.
      • Vlaeyen J.W.
      • Weber W.E.
      The joint contribution of physical pathology, pain-related fear and catastrophizing to chronic back pain disability.
      • Vlaeyen J.W.
      • Kole-Snijders A.M.
      • Boeren R.G.
      • van Eek H.
      Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance.
      • Vlaeyen J.W.
      • Kole-Snijders A.M.
      • Rotteveel A.M.
      • Ruesink R.
      • Heuts P.H.
      The role of fear of movement/(re)injury in pain disability.
      However, it has also been recognized that not all CLBP patients show a fear of movement, but that there may be a subgroup of patients who react with endurance rather than avoidance when faced with pain.
      • Hasenbring M.I.
      • Hallner D.
      • Klasen B.
      • Streitlein-Böhme I.
      • Willburger R.
      • Rusche H.
      Pain-related avoidance versus endurance in primary care patients with subacute back pain: psychological characteristics and outcome at a 6-month follow-up.
      • Hasenbring M.I.
      • Verbunt J.A.
      Fear-avoidance and endurance-related responses to pain: new models of behavior and their consequences for clinical practice.
      • Turk D.C.
      • Robinson J.P.
      • Burwinkle T.
      Prevalence of fear of pain and activity in patients with fibromyalgia syndrome.
      In addition, the disuse/deconditioning for CLBP patients was not unequivocally confirmed.
      • Smeets R.J.
      • Wade D.
      • Hidding A.
      • van Leeuwen P.J.
      • Vlaeyen J.W.
      • Knottnerus J.A.
      The association of physical deconditioning and chronic low back pain: A hypothesis-oriented systematic review.
      • Verbunt J.A.
      • Seelen H.A.
      • Vlaeyen J.W.
      • van den Heijden G.J.
      • Heuts P.H.
      • Pons K.
      • Knottnerus J.A.
      Disuse and deconditioning in chronic low back pain: Concepts and hypotheses on contributing mechanisms.
      Despite the FA model's pervasiveness, little is known about the neural correlates of the postulated fear. In an earlier study we investigated the neural correlates of viewing back-straining movements with an event-related functional magnetic resonance imaging (fMRI) study
      • Barke A.
      • Baudewig J.
      • Schmidt-Samoa C.
      • Dechent P.
      • Kröner-Herwig B.
      Neural correlates of fear of movement in high and low fear-avoidant chronic low back pain patients: An event-related fMRI study.
      and expected to find neural activities in structures related to fear processing, such as the amygdala, insula, cingulate gyrus, fusiform gyrus, and the substantia nigra.
      • Etkin A.
      • Wager T.D.
      Functional neuroimaging of anxiety: A meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia.
      However, we failed to find any neural correlates of fearful processing of such pictures of back-straining movements in high fear-avoidant CLBP participants, despite the fact that their fear processing in general was unimpaired.
      One major limitation of our previous study was that the participants only passively viewed the photographs of the movements and thus it could not be excluded that they may have focused on other aspects of the pictures and failed to relate the movement to themselves. To address this limitation, the present study specifically instructed the participants to imagine that they themselves were performing the movements shown in the pictures. Moreover, we tested a much larger sample (n = 93) and included men.
      We used an fMRI block design to compare CLBP patients with HFA and LFA and healthy pain-free participants when they imagined executing back-straining and neutral movements. We hypothesised that when patients with high fear-avoidance (HFA) imagined back-straining movements as opposed to neutral movements, they would show activations in regions related to fear processing. We also hypothesised that these activations would be more pronounced for patients with HFA than for patients with LFA or for controls.

      Methods

      Participants

      Recruitment

      Patients with CLBP were recruited via local rehabilitation centers and newspaper advertisements. Patients were included if the location of their back pain was the lower back, the pain had persisted for at least 6 months and they reported an average pain intensity of at least 5 on a numerical rating scale from 0 to 10 (with 0 being ‘no pain’ and 10 being the ‘worst imaginable pain’) over the previous 4 weeks. Specific causes of their back pain had been ruled out by their physicians. Healthy controls were recruited via newspaper advertisements. All of the participants were screened for further pain conditions, neurological disorders, and standard magnetic resonance imaging (MRI) contraindications, such as metal objects in the body. In addition, the German version of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition Axis I Disorders (SCID I)
      • Wittchen H.U.
      • Zaudig M.
      • Fydrich T.
      Structured clinical interview for DSM-IV.
      was conducted with each participant to exclude any mental disorders.

      Sample Characteristics

      Ninety-three persons (mean age 49.7 ± 9.2 years) participated in the study. Of these participants, 62 suffered from unspecific CLBP and 31 were pain-free controls matched for age and sex (HC). The participants with CLBP were divided by means of a median split performed on the basis of their scores in the German version of the Tampa Scale of Kinesiophobia (TSK)
      • Kori S.
      • Miller R.
      • Todd D.
      Kinesiophobia: A new view of chronic pain behavior.
      • Rusu A.C.
      • Kreddig N.
      • Hallner D.
      • Hülsebusch J.
      • Hasenbring M.
      Fear of movement/(re)injury in low back pain: Confirmatory validation of a German version of the Tampa Scale for Kinesiophobia.
      into persons with HFA (TSK > 34.5; n = 31) and LFA (TSK < 34.5; n = 31).
      For a full characterization of the groups, including pain duration, pain intensity, and age see Table 1.
      Table 1Participant Characteristics
      LFA (n = 31)

      17 Female/14 Male
      HFA (n = 31)

      16 Female/15 Male
      HC (n = 31)

      18 Female/13 Male
      F2,90η2
      MeanSDMeanSDMeanSD
      Age47.99.251.89.949.38.21.46-
      STAI-trait34.58.336.09.030.26.73.87*.082
      STAI-state39.18.940.212.034.99.62.23-
      CES-D15.08.414.18.27.75.28.63***.164
      t60d
      TSK29.33.639.13.810.38***2.64
      Pain duration (years)12.38.812.010.0.15-
      Average pain
      Pain ratings on a numerical rating scale ranging from 0 (‘no pain’) to 10 (‘worst pain imaginable’) over the previous 4 weeks.
      6.01.27.01.52.88**.73
      Minimum pain
      Pain ratings on a numerical rating scale ranging from 0 (‘no pain’) to 10 (‘worst pain imaginable’) over the previous 4 weeks.
      3.02.14.42.52.37*.60
      Maximum pain
      Pain ratings on a numerical rating scale ranging from 0 (‘no pain’) to 10 (‘worst pain imaginable’) over the previous 4 weeks.
      7.61.07.91.71.01-
      PDI mean2.71.73.62.11.75-
      PCS15.511.518.49.91.03-
      NOTE. LFA indicates chronic low back pain patients with low fear-avoidance; HFA, chronic low back pain patients with high fear-avoidance; and HC, healthy pain-free control participants. A χ2 test showed no difference for sex between the groups (χ2 = .26, df = 2, P > .05). For CES-D, Tukey post hoc tests showed: HC was lower than both CLBP groups, all P < .01. For STAI-trait, Tukey post hoc tests showed: HFA was higher than HC, P < .05.
      *P < .05.
      **P < .01.
      ***P < .001.
      Pain ratings on a numerical rating scale ranging from 0 (‘no pain’) to 10 (‘worst pain imaginable’) over the previous 4 weeks.

      Design

      A 3 × 2 repeated measures design with the between-factor group (HFA, LFA, and HC) and the within-factor movement type (back-straining and neutral) was used.

      Psychometric Instruments

      Pain Characteristics and Fear of Movement

      Pain duration, location, and intensity as well as other pain characteristics were assessed using the pain questionnaire of the German chapter of the International Association for the Study of Pain (Deutscher Schmerzfragebogen).

      Nagel B, Gerbershagen HU, Lindena G, Pfingsten M: Development and empirical validation of the German pain questionnaire of the DGSS [in German]. Pain 16:263-270, 2002

      The participants rated the average, maximum, and minimum pain intensity they had experienced in the previous 4 weeks on a numerical rating scale from 0 to 10 (with 0 being ‘no pain’ and 10 representing the ‘worst imaginable pain’). Pain-related disability was assessed using the German version of the Pain Disability Index (PDI).
      • Dillmann U.
      • Nilges P.
      • Saile H.
      • Gerbershagen H.U.
      • Pollard C.A.
      Preliminary validity study of the Pain Disability Index.
      The PDI measures subjective disability (ie, the extent to which the chronic pain interferes with the person's ability to engage in everyday activities). The instrument consists of 7 items to be rated from 0 to 10 (with 0 being ‘no disability’ and 10 being ‘total disability’), which cover the following areas: family/home responsibilities; recreation; social activities; occupation; sexual behavior; self-care and life-support activities. Catastrophizing cognitions were assessed using the German version of the Pain Catastrophizing Scale (PCS).
      • Meyer K.
      • Sprott H.
      • Mannion A.F.
      Cross-cultural adaptation, reliability, and validity of the German version of the Pain Catastrophizing Scale.
      • Sullivan M.J.
      • Bishop S.R.
      • Pivik J.
      The Pain Catastrophizing Scale: Development and validation.
      Pain catastrophizing denotes the tendency to experience pain as very threatening and to exaggerate its seriousness. The PCS consists of 13 statements regarding what the person may think or feel when they are in pain (example item: ‘It's terrible and I think it's never going to get any better’) and the participants have to judge their agreement with each statement on a 5-point rating scale (0 = ‘not at all’ to 4 = ‘all the time’).
      The fear of movement was assessed with the TSK.
      • Kori S.
      • Miller R.
      • Todd D.
      Kinesiophobia: A new view of chronic pain behavior.
      • Rusu A.C.
      • Kreddig N.
      • Hallner D.
      • Hülsebusch J.
      • Hasenbring M.
      Fear of movement/(re)injury in low back pain: Confirmatory validation of a German version of the Tampa Scale for Kinesiophobia.
      The TSK is a reliable instrument for the assessment of fear of movement in CLBP patients, with satisfactory internal consistency (Cronbach α = .76–.84)
      • French D.J.
      • France C.R.
      • Vigneau F.
      • French J.A.
      • Evans R.T.
      Fear of movement/(re)injury in chronic pain: A psychometric assessment of the original English version of the Tampa scale for kinesiophobia (TSK).
      and consists of 17 statements expressing fear of physical activity (eg, ‘I'm afraid that I might injure myself if I exercise’), which have to be rated on a 4-point rating scale from 1 = ‘strongly disagree’ to 4 = ‘strongly agree.’ The scales for items 4, 8, 12, and 16 are inverted.

      Depression and Anxiety

      Manifest depression was excluded through the SCID I interview. To measure depression as a dimensional construct, we used the Center for Epidemiologic Studies Depression Scale (CES-D).

      Hautzinger M: The CES-D Scale: An instrument to measure depression in investigations of the general population [in German]. Diagnostica 34:167–173, 1988

      • Radloff L.S.
      The CES-D scale: A self-report depression scale for research in the general population.
      The CES-D is well suited to assessing depression in clinical and nonclinical populations and consists of 20 items pertaining to various possible symptoms of depression (example item: ‘I felt depressed’). For each item, the participants had to rate on a 4-point scale the number of days during the previous week that he or she had experienced the symptom being described (0 = ‘rarely’ [less than 1 day], 1 = ‘sometimes’ [1–2 days], 2 = ‘often’ [3–4 days], 3 = ‘most of the time’ [5–7 days]). The items 4, 8, 12, and 16 are scored inversely.
      Trait and state anxiety were measured with the German version of the State-Trait-Anxiety Inventory (STAI).
      • Laux L.
      • Glanzmann P.
      • Schaffner P.
      • Spielberger C.
      The State-Trait-Anxiety Inventory (STAI).
      • Spielberger C.
      • Gorsuch R.
      • Lushene R.
      Manual for the State-Trait-Anxiety Inventory.
      The state version consists of 20 items describing thoughts or feelings related to fearful, worried states (example item: ‘I feel tense’), for which the person has to rate on a scale from 1 = ‘not at all’ to 4 = ‘very much so’ how much the statement describes how they presently feel. Half of the items (1, 2, 5, 8, 10, 11, 15, 16, 19, 20) are scored inversely. The trait version also consists of 20 items describing a fearful and worried disposition (example item: ‘I worry too much over something that really does not matter’). The person has to rate on a scale from 1 = ‘almost never’ to 4 ‘almost always’ whether these statements describe how they feel in general. The items (1, 6, 7, 10, 13, 16, 19) are scored inversely.

      Stimulus Material

      A total of 48 color photographs of movements and postures served as stimulus material. The pictures were identical to the movement pictures we used in our previous study.
      • Barke A.
      • Baudewig J.
      • Schmidt-Samoa C.
      • Dechent P.
      • Kröner-Herwig B.
      Neural correlates of fear of movement in high and low fear-avoidant chronic low back pain patients: An event-related fMRI study.
      Most pictures were taken from the Photograph Series of Daily Activities (PHODA),
      • Kugler K.
      • Wijn J.
      • Geilen M.
      • De Jong J.
      • Vlaeyen J.W.
      The photograph series of daily activities (PHODA) (CD-ROM version 1).
      supplemented by pictures produced by one of the authors (A.B.). The photographs were selected from a larger pool of 138 pictures on the basis of a pilot study with 21 CLBP patients and 20 controls. For more detail of the picture selection process see Barke et al.
      • Barke A.
      • Baudewig J.
      • Schmidt-Samoa C.
      • Dechent P.
      • Kröner-Herwig B.
      Neural correlates of fear of movement in high and low fear-avoidant chronic low back pain patients: An event-related fMRI study.
      Twenty-four photographs each depicted either back-straining or neutral movements and postures (Fig 1). The back-straining movements showed activities that CLBP patients normally avoid, such as bending down or lifting heavy boxes (numbers of the PHODA pictures used: 1, 2, 3, 4, 20, 22, 29, 31, 46, 57, 64, 65, 68, 76, 82, 83, 85, 87, 88, 91, 99). The neutral movements showed less strenuous activities, such as sitting, standing, or walking (they also included a few PHODA pictures: 8, 60, 61, 69, 84, 92).
      Figure thumbnail gr1
      Figure 1Example pictures of back-straining movement (left) and a neutral movement (right). The left picture is part of the PHODA,
      • Kori S.
      • Miller R.
      • Todd D.
      Kinesiophobia: A new view of chronic pain behavior.
      the right picture was taken by A.B.

      Procedure

      The study protocol was approved by the Ethics Committee of the University Medical Center, Göttingen. Before their participation, the participants received full written information about the study and signed an informed consent form. The participants received a small amount of financial compensation for their participation in the study and a CD with the anatomical pictures of their brains.
      All participants attended 2 separate appointments. During the first appointment, the SCID I interview was carried out and the participants received the questionnaires, which they filled in at home and brought with them for the second appointment. During the second appointment, the MRI scanning took place. Immediately before the MRI session, the participants filled in the state version of the STAI to assess their anxiety before the scan. The participants were then placed in the MRI scanner in a supine position, wearing foam earplugs for noise protection and headphones for communication with the experimenter and additional noise protection. After the anatomical reference scans, the functional imaging commenced and the pictures were presented to the participants using magnetic resonance compatible LCD goggles with a resolution of 800 × 600 (Resonance Technology, Northridge, CA). If a participant required glasses, corrective lenses were combined with the goggles to ensure corrected-to-normal vision.

      Stimulation Paradigm

      The pictures were presented in alternating (back-straining/neutral) blocks. Each block lasted 24 seconds and contained 4 pictures, presented for 6 seconds each, either of back-straining movements (back-straining) or neutral movements (neutral). Twelve back-straining and 12 neutral blocks were shown, resulting in a total duration of 9.6 minutes. Each picture was presented twice. The picture order was randomised except for the block structure. The participants were instructed to look at the pictures and to imagine that they themselves were executing the activity shown in the picture.

      Image Acquisition

      The MRI scans were acquired at 3 Tesla (Siemens Magnetom TIM Trio; Siemens Healthcare, Erlangen, Germany) with an 8-channel phased-array head coil. For anatomical reference, a 3-D T1-weighted data set was acquired (turbo fast low angle shot; echo time = 3.26 ms; repetition time = 2,250 ms; inversion time = 900 ms; flip angle = 12°; isotropic resolution = 1 × 1 × 1 mm3). The functional data sets were acquired using T2*-weighted gradient-echo echo-planar imaging (echo time = 36 ms, repetition time = 2000 ms, flip angle = 70°, 22 slices of 4 mm thickness at an in-plane resolution of 2 × 2 mm2). A total of 288 whole-brain volumes were recorded within the functional run. To reach magnetic saturation, 4 preparatory scans were acquired and subsequently discarded from the analyses.

      Stimulus Ratings

      After the scanning session, the participants were asked to view the pictures again, this time on a computer screen, and to rate each movement in terms of valence and arousal on a 9-point scale using the computerized version of the self-assessment manikin.
      • Bradley M.M.
      • Lang P.J.
      Measuring emotion: The self-assessment manikin and the semantic differential.
      For valence the instruction was: ‘Please rate: how positive/negative is the depicted movement for you personally?’; for arousal it was: ‘Please rate: how strong is the arousal you feel with respect to the depicted movement?’ The end points of the valence scale were marked as ‘very negative’ and ‘very positive,’ and the end points of the arousal scale were ‘none’ and ‘very strong.’ Each picture was presented separately and the order of presentation was randomized. The picture remained visible until the participant had rated it and pressed the button labelled ‘next.’ The ratings of 2 participants were not recorded because of a technical problem. The imagining was not measured directly, because doing so would have disturbed the act of imagining the actions. However, at the end of the experiment we interviewed the participants as to whether they found it hard to imagine the movements in the timeframe and whether they had succeeded in doing so. The answers indicated that the participants had indeed imagined the depicted actions and postures (and nearly all participants recalled spontaneously some of the movements telling us how they went about it).

      Data Analysis

      Functional Data

      The functional data were analyzed using Brain Voyager QX Software version 2.1.2 (Brain Innovation, Maastricht, The Netherlands). Standard preprocessing steps included 3-D motion correction, slice scan time correction, temporal filtering (linear trend removal and high-pass filtering) and spatial smoothing with a Gaussian kernel (full width at half maximum 8 × 8 × 8 mm3). For high pass filtering and linear trend removal, the presence of low frequencies was estimated and removed using a general linear model containing sines and cosines (up to 2 cycles per run, .0034 Hz). The filtering was performed in the time domain using the general linear model to estimate and remove the contributions of low frequencies in each voxel's time course. The functional data sets were coregistered to the anatomical reference scans and transformed into Talairach space. A brain mask was generated on the basis of the Talairach-transformed anatomic images. Subsequent functional analyses were restricted to the voxels in this mask. Group analysis was performed using the multisubject (random effects) approach of the general linear model. In a first step, the 24-second duration of each block (boxcar) was convolved with the canonical hemodynamic response function resulting in 2 predictors (back-straining movements, neutral movements) for the types of movement. On the basis of these predictors, β values were estimated for each voxel, which express the strength of the predictor for that voxel. This step included a percentage normalization of the raw blood oxygen level-dependent signal time-courses to account for differences in mean blood oxygen level-dependent signal levels across voxels or subjects. In a first step, β maps for the contrast (back-straining > neutral) were generated for each participant. In the second-level analysis, the β maps were used to examine the effect of movement type across all participants, regardless of group membership, and for each group individually. For these analyses, the Bonferroni-corrected results are reported. In a second step, the groups were compared in planned contrasts and the contrasts between HFA > LFA, HFA > HC, and LFA > HC are reported. For the group comparisons, the uncorrected cluster threshold was set at P = .001. On the basis of the number of activated voxels and the estimated smoothness of the map, Monte-Carlo simulations (1,000 iterations) were performed to determine the minimum cluster size required to yield an error rate of no more than P < .05 at the cluster level. Activations were assigned to anatomical locations according to the nearest coordinates in the Talairach Daemon database.
      • Lancaster J.
      • Rainey L.
      • Summerlin J.
      • Freitas C.
      • Fox P.
      • Evans A.
      • Toga A.
      • Mazziotta J.
      Automated labeling of the human brain: A preliminary report on the development and evaluation of a forward-transform method.
      • Lancaster J.
      • Woldorff M.
      • Parsons L.
      • Liotti M.
      • Freitas C.
      • Rainey L.
      • Kochunov P.
      • Nickerson D.
      • Mikiten S.
      • Fox P.
      Automated Talairach Atlas labels for functional brain mapping.
      Often, clusters span several structures. For these, we report the cluster maxima. In addition, further activated structures are included in the tables whenever a local maximum of the t-score was located in the structure. A local maximum is defined as a maximum at least 10 mm apart from the next maximum. If 2 local maxima are closer together, only the maximum with the higher statistical value is reported and the other is suppressed. For each structure, only the maximum with the highest statistical value is reported.
      For a correlation analysis, CLBP patients with HFA and LFA were pooled and voxelwise correlations with the TSK score were calculated. The uncorrected threshold was set at P = .001 and cluster level corrections applied.
      All clusters quoted in this study are numbered consecutively.

      Questionnaire Data and Stimulus Ratings

      Questionnaire data pertaining to the participants of all 3 groups (CES-D and STAI) as well as age were compared between the groups using 1-way analysis of variance (ANOVA), using Tukey post hoc tests, when appropriate. For measures applicable to the participants with back pain only (TSK, PDI, PCS, pain duration, pain intensity) independent t-tests (2-tailed) were used to compare the high and low fear-avoidant participants. As measures of effect size, Cohen's d and η2 were calculated.
      With regard to the valence and arousal ratings collected after the scanning session, we calculated two 3 × 2 repeated measures ANOVAs for valence and arousal of the movements with the between-subject factor group (HFA, LFA, HC) and the within-subject factor movement type (back-straining, neutral). In cases in which Mauchly test indicated that the sphericity assumption had been violated, Greenhouse–Geisser corrections were performed and the resulting values reported. Tukey post hoc tests were used for further analyses.

      Results

      Stimulus Ratings

      Valence and Arousal Ratings for the Neutral and Back-Straining Movements

      Valence

      The 3 × 2 repeated measures ANOVA for the valence ratings of the movements with the between-subjects factor group and the within-subjects factor movement type showed no main effect for group (P > .10), but revealed a main effect for movement type (F1,88 = 368.06, P < .001, η2 = .629) and an interaction group × movement type (F2,88 = 5.16, P < .005, η2 = .018). Tukey post hoc tests showed that, within each group, the back-straining movements were rated more negatively than the neutral movements (all Ps < .001). Tukey tests found no significant differences between the neutral movements between the groups. For the back-straining movements, the HFA and the LFA CLBP patients rated the pictures as more negative than the HC (all Ps < .01), but did not differ from each other (P > .10; see Fig 2 for more detail).
      Figure thumbnail gr2
      Figure 2Valence and arousal ratings for the stimuli as a function of group and movement type. Error bars show standard deviations. For the valence ratings, low numbers indicate negative valence (1 = very negative to 9 = very positive). For the arousal ratings, low numbers indicate low levels of arousal (1 = no arousal to 9 = extreme arousal). HFA indicates high fear-avoidant chronic low back pain patients; LFA, low fear-avoidant chronic low back pain patients; and HC, healthy pain-free participants.

      Arousal

      The 3 × 2 repeated measures ANOVA for the arousal ratings showed main effects for group (F2,88 = 5.95, P < .005, η2 = .070) and movement type (F1,88 = 106.61, P < .001, η2 = .213), and an interaction Group × Movement (F2,88 = 5.29, P < .01, η2 = .021). Tukey post hoc tests showed that, within each group, the back-straining movements were rated as more arousing than the neutral movements (all Ps < .005). Tukey post hoc tests for group showed that HFA pain patients rated the movements as more arousing than HC (P < .01) and so did LFA patients (P < .01); however, no difference was observed between HFA and LFA. Post hoc tests for group × movement showed that the HFA as well as the LFA rated the back-straining movements as more arousing than the HC (HFA: P < .001; LFA: P < .05), but did not differ from each other. The neutral pictures were rated equally nonarousing by all groups (see Fig 2 for more detail).

      Imaging Results

      Back-Straining Movements > Neutral Movements

      All participants

      Across all groups imagining back-straining movements evoked stronger activations than imagining neutral movements in the right middle temporal gyrus (1; cluster numbers in parentheses), the right inferior parietal lobule (3), the bilateral superior parietal lobules (2, 4), the left middle frontal gyrus (6), and the left precentral gyrus (5). These structures were the locations of the clusters’ peak voxels. However, the clusters extended to adjacent structures (see Table 2 for a complete list). The inverse contrast (neutral movements > back-straining movements) activated the left posterior cingulate cortex (8) and the right cuneus (7).
      Table 2Structures Activated for the Contrast Back-Straining Movements > Neutral Movements and the Reverse Contrast Across All Groups (N = 93; Bonferroni Corrected; Total Area Activated: 104,557 mm3)
      Anatomical DescriptionRL
      xyztClusterBAxyztClusterBA
      Back-straining > neutral
       Middle occipital gyrus57−68−67.15118, 19−59−71−66.51119
       Middle temporal gyrus44−62011.851b37 (V5)
       Lingual gyrus14−80−910.28117, 18−7−68−37.97118
       Cuneus14−10235.76118−25−92311.09118
       Fusiform gyrus−37−71−128.40119
       Inferior temporal gyrus−49−68−311.59137
       Inferior parietal lobule35−50576.93240−34−44428.18440
      32−35395.743b40
       Superior parietal lobule26−53489.182b7−28−53549.604b7
       Middle frontal gyrus−19−8575.5756
      −4037216.126b46
       Precentral gyrus−25−14516.985b6
       Cerebellum, declive23−68−1210.351−25−71−158.301
       Cerebellum, culmen−31−56−217.261
      Neutral > back-straining
       Posterior cingulate14−56127.56730−16−59127.218b30
       Cuneus2−801812.557b18
      Abbreviations: R, right; L, left; BA, Brodmann area.
      NOTE. Cluster sizes (mm3): 1 = 72,142; 2 = 5,071; 3 = 145; 4 = 16,349; 5 = 750; 6 = 236; 7 = 9,061; 8 = 803. Cluster maxima are marked with a superscript b.

      CLBP participants with HFA

      When HFA participants imagined executing back-straining movements as opposed to neutral movements, the right middle occipital gyrus (9, 10), the left inferior temporal gyrus (15), the bilateral superior parietal lobuli (11, 14), the left cuneus (13), and areas in the right cerebellum (12) were activated (see Table 3 for a complete list and Fig 3 middle column). The inverse contrast evoked activations in the right cuneus (16).
      Table 3Structures Activated for the Contrast Back-Straining Movements > Neutral Movements and the Reverse Contrast Within the HFA (Bonferroni-Corrected; Total Area Activated 13,884 mm3)
      Anatomic DescriptionRL
      xyztClusterBAxyztClusterBA
      Back-straining > neutral
       Middle occipital gyrus50−65−67.129b37
      29−8068.1410b18
       Cuneus20−9267.251017−25−9238.0213b18
       Superior parietal lobule26−53486.1411b7−31−56547.0114b7
       Inferior temporal gyrus−49−68−36.6215b37
       Cerebellum, declive11−80−126.7710
      26−65−216.4512b
      Neutral > back-straining
       Cuneus2−80186.9716b18
      Abbreviations: R, right; L, left; BA, Brodmann area.
      NOTE. Cluster sizes (mm3): 9 = 2,296; 10 = 4,937; 11 = 228; 12 = 1,416; 13 = 1,171; 14 = 1,179; 15 = 1,146; 16 = 1,511. Cluster maxima are marked with a superscript b.
      Figure thumbnail gr3
      Figure 3Bonferroni-corrected activation maps for the within-group contrast back-straining movements > neutral movements. Left column: healthy pain-free participants; middle column: high fear-avoidant chronic low back pain patients; right column: low fear-avoidant chronic low back pain patients. The statistical maps are shown overlaid on the averaged T1-weighted data set of all subjects.

      CLBP participants with LFA

      In the LFA group, imagining executing back-straining movements activated the right fusiform gyrus (17) and the left inferior temporal gyrus (18). The inverse contrast evoked activations in the bilateral posterior cingulate (19, 21) and the right cuneus (20) (see Table 4 for a complete list and Fig 3 right column).
      Table 4Structures Activated for the Contrast Back-Straining Movements > Neutral Movements and the Reverse Contrast Within the LFA (Bonferroni Corrected; Total Area Activated 6,739 mm3)
      Anatomical DescriptionRL
      xyztClusterBAxyztClusterBA
      Back-straining > neutral
       Fusiform gyrus38−56−35.6817b37
       Inferior temporal gyrus−49−71−35.9218b19
      Neutral > back-straining
       Posterior cingulate14−56156.2119b30−16−5612−6.0121b30
       Cuneus2−77189.1020b18
      Abbreviations: R, right; L, left; BA, Brodmann area.
      NOTE. Cluster sizes (mm3): 17 = 239; 18 = 194; 19 = 1,006; 20 = 4,892; 21 = 408. Cluster maxima are marked with a superscript b.

      Pain-free control participants

      When HC participants imagined carrying out back-straining movements as opposed to neutral movements, the bilateral occipital gyri (22, 25), the right inferior and superior parietal lobule (23, 24), the left precuneus (27) and cuneus (26), the left inferior temporal gyrus (29), and the declive (cerebellum) (28) were activated, whereas the inverse contrast evoked activations in the right cuneus (30) (see Table 5 for a complete list and Fig 3, left column).
      Table 5Structures Activated for the Contrast Back-Straining Movements > Neutral Movements and the Reverse Contrast Within the HC (Bonferroni Corrected; Total Area Activated 25,269 mm3)
      Anatomic DescriptionRL
      xyztClusterBAxyztClusterBA
      Back-straining > neutral
       Middle occipital gyrus44−6539.3722b37−25−9266.9325b18
       Cuneus26−77157.522218−25−83245.9426b19
       Lingual gyrus20−8638.602217
       Inferior parietal lobule35−47545.9823b40−37−47486.192740
       Superior parietal lobule26−53485.6024b7
       Fusiform gyrus−37−71−125.482819
       Precuneus−25−56546.4527b7
       Inferior temporal gyrus−46−7108.0629b
      Cerebellum, declive23−68−127.3422−19−65−126.35928b
      Neutral > back-straining
       Cuneus2−83215.9930b18
      Abbreviations: R, right; L, left; BA, Brodmann area.
      NOTE. Cluster sizes (mm3): 22 = 15,575; 23 = 183; 24 = 531; 25 = 1,541; 26 = 172; 27 = 1,627; 28 = 1,650; 29 = 3,397; 30 = 593. Cluster maxima are marked with a superscript b.

      Group Comparisons

      HFA > LFA

      Comparing HFA patients imagining back-straining movements as opposed to neutral movements with LFA patients, we found that the HFA showed stronger activations in the right hippocampus (32), the right parahippoccampal gyrus (31), and the left middle temporal gyrus (33). The inverse contrast (LFA > HFA) was empty (Table 6 and Fig 4, left column). For the clusters identified by the contrast HFA > LFA we calculated the β differences back-straining movements > neutral movements for all groups, including the control group (Fig 5).
      Table 6Structures Activated for the Group Comparisons HFA > LFA and HC > LFA (P < .001, Cluster Level Corrected; All Other Group Comparisons Were Empty)
      Anatomic DescriptionRL
      xyztClusterBAxyztClusterBA
      HFA > LFA
       Parahippocampal gyrus32−5694.4331b30
       Hippocampus23−20−155.1632b28
       Middle temporal gyrus−31−59155.0333b19
      HC > LFA
       Hippocampus26−17−154.8934b28
       Lingual gyrus29−5964.3135b19
      Abbreviations: R, right; L, left; BA, Brodmann area.
      NOTE. Cluster sizes (mm3): 31 = 574; 32 = 967; 33 = 897; 34 = 604; 35 = 560. Cluster maxima are marked with a superscript b.
      Figure thumbnail gr4
      Figure 4Second-level comparisons (between group) of the contrast back-straining movements > neutral movements. The statistical maps were cluster-level corrected and are shown overlaid on the averaged T1-weighted data set of all subjects. HFA indicates high fear-avoidant chronic low back pain patients; LFA, low fear-avoidant chronic low back pain patients; and HC, healthy pain-free participants.
      Figure thumbnail gr5
      Figure 5β Values of the predictors for the clusters 31–33 (AC). Please note that the clusters were extracted on the basis of the contrast HFA > LFA (shown in black) and the values for HC (shown in grey) are only provided for purposes of comparison. HFA indicates high fear-avoidant chronic low back pain patients; LFA, low fear-avoidant chronic low back pain patients; and HC, healthy pain-free participants.

      HFA > HC

      No differences were found between the back pain participants with HFA and the pain-free control participants.

      LFA > HC

      For the contrast LFA > HC, no activations were found. Inversely, pain-free controls showed stronger activations in the right hippocampus (34) and the right lingual gyrus (35) than LFA patients (see Table 6 and Fig 4, right column).

      Correlations With the TSK

      Combining the back pain patients into 1 group (HFA and LFA: n = 62) and calculating the correlation of the contrast back-straining movements > neutral movements with the TSK score showed no regions above the threshold of P < .001.

      Discussion

      We investigated the neural correlates of imagining back-straining movements in high and low fear-avoidant CLBP patients using fMRI and compared them with those of pain-free controls. Patients with LFA differed from patients with HFA and pain-free controls, but contrary to expectations, patients with HFA and control participants did not show any differences in their neural correlates. On a behavioral level, back pain patients rated the back-straining movements as more negative and more arousing than did pain-free control participants.
      The main effect for movement type, imagining back-straining movements relative to neutral movements, evoked activations in areas that Caspers and colleagues identified in their meta-analysis
      • Caspers S.
      • Zilles K.
      • Laird A.R.
      • Eickhoff S.B.
      ALE meta-analysis of action observation and imitation in the human brain.
      as consistently involved in action observation and imitation (eg, middle occipital gyrus, fusiform gyrus, superior parietal lobule, precentral gyrus). Imagined actions are represented similarly to overtly performed and observed actions.
      • Oosterhof N.
      • Tipper S.
      • Downing P.
      Visuo-motor imagery of specific manual actions: A multi-variate pattern analysis fMRI study.
      Because back-straining movements (eg, lifting a heavy-looking box) were more complex activities than neutral movements (eg, standing, sitting), this seems to indicate that the participants indeed followed the instructions and observed and imagined the presented movements.
      When they imagined back-straining movements in contrast to neutral movements, patients with HFA showed stronger activations in the right anterior (ventral) hippocampus, the right parahippocampal gyrus, and the left middle temporal gyrus than the low fear-avoidant patients. The hippocampus receives afferents from the septum and the area entorhinalis; its efferents reach the thalamus and the gyrus cingulum and it is reciprocally connected with the basal amygdala.
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      Chronic pain has been reported to affect hippocampus size and connectivity.
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      Evidence of anatomical and functional variability along the hippocampal long axis has inspired different proposals of long-axis functional specialization.
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      The dorsal hippocampus is primarily associated with cognitive functions (eg, spatial navigation)
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      whereas the anterior hippocampus is involved in emotion, stress, and affect.
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      In particular, the anterior hippocampus was shown to play an important role in anxiety: in animal studies, lesions in the ventral hippocampus were consistently associated with reduced anxiety in a number of standard anxiety paradigms.
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      In humans, the anterior hippocampus is involved in the modulation of pain through anxiety.
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      Individual sensitivity to pain expectancy is related to differential activation of the hippocampus and amygdala.
      Activation in the right hippocampus was positively correlated (r = .74) with high pain expectancy sensitivity during the expectancy of a painful thermal stimulation,
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      Individual sensitivity to pain expectancy is related to differential activation of the hippocampus and amygdala.
      and the hippocampus found to be differentially activated in response to identical noxious stimuli, depending on whether the perceived pain was enhanced by pain-related anxiety. In the context of the present study, anterior hippocampus activation may indicate that imagining back-straining movements in contrast to neutral movements triggered pain-related representations to arise in high fear-avoidant participants, but not in low fear-avoidant participants. This is in accordance with the predictions of the FA model. The findings can be interpreted as the neural correlates of anxiety induced by imagining back-straining movements. The anxiety in turn may lead to the extensive avoidance behavior shown by the high fear-avoidant patients.
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      Apart from the anterior hippocampus, another part of the hippocampal formation, the right parahippocampal gyrus, was also more strongly activated in high fear-avoidant than in low fear-avoidant CLBP patients. The parahippocampal gyrus has been associated with the reactivation of pain memories
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      Fear conditioning in an abdominal pain model: Neural responses during associative learning and extinction in healthy subjects.
      and pain sensitivity.
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      Dissection of perceptual, motor and autonomic components of brain activity evoked by noxious stimulation.
      The reported peak coordinates differ considerably between the studies; the coordinates resembling most closely those found in the present study were associated by Roy and colleagues
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      Cerebral and spinal modulation of pain by emotions.
      with the cerebral modulation of pain by emotions.
      The high fear-avoidant CLBP patients also showed a stronger activation in the middle temporal gyrus than the low fear-avoidant patients. According to Palermo and colleagues,
      • Palermo S.
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      • Costa T.
      • Amanzio M.
      Pain anticipation: An activation likelihood estimation meta-analysis of brain imaging studies.
      in their activation likelihood estimation meta-analysis of fMRI studies, the middle temporal gyrus is associated with pain anticipation, perhaps indicating that HFA leads to pain anticipation when confronted with back-straining movements.
      Healthy controls also revealed stronger activations in the anterior hippocampus, and in addition in the lingual gyrus, than low fear-avoidant participants. Both hippocampal clusters (differentiating the low fear-avoidant participants from the high fear-avoidant participants and from healthy controls) overlapped extensively. This was unexpected, because the healthy controls did not suffer from chronic pain and the classical FA model postulates that the movement–pain connections are learned in the acute phase of the back pain. However, even if a person does not suffer from chronic back pain, he or she may distinguish between back-straining movements and neutral movements on an affective level. After all, back-straining movements are generally more strenuous and even pain-free persons estimated them as potentially more harmful.
      • Buer N.
      • Linton S.
      Fear-avoidance beliefs and catastrophizing: Occurrence and risk factor in back pain and ADL in the general population.
      In our study, this is borne out by the fact that all participants, including the pain-free controls, rated the back-straining movements as more negative and arousing than the neutral ones. In healthy persons this may not influence daily living; however, when confronted with chronic pain, such fear-avoidance has a major effect on disability outcomes.
      • Zale E.
      • Lange K.
      • Fields S.
      • Ditre J.
      The relation between pain-related fear and disability: A meta-analysis.
      Remarkably, a direct comparison of healthy controls and high fear-avoidant patients showed no differences in neural correlates at all. The absence of a difference between healthy controls and high fear-avoidant back pain patients—even though at odds with the FA model—is in line with our first study.
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      Neural correlates of fear of movement in high and low fear-avoidant chronic low back pain patients: An event-related fMRI study.
      In that study, the participants only passively viewed the pictures. Therefore, the question remained open as to whether the absence of differences between high fear-avoidant patients and pain-free participants could be attributed to the fact that the participants failed to relate the presented movements to their own person. In the present study, we can now rule out this explanation. In addition, Lloyd and colleagues, who compared neural responses with intense (nonpainful) tactile stimulation to the lower back between healthy controls and CLBP patients with poor adjustment did not find any differences between the 2 groups.
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      Differences in low back pain behavior are reflected in the cerebral response to tactile stimulation of the lower back.
      There are some important differences between the results of Lloyd and colleagues and the present study: They did not investigate fear-avoidance directly and used tactile lower back stimulation. However, despite these differences it is remarkable that in both studies no differences in neural responses were found between healthy controls and pain patients with low adjustment and yet both groups differed in their reaction from patients who adjust well to their chronic pain.
      To analyze this unexpected similarity between high fear-avoidant participants and healthy controls further, we also showed the β differences (back-straining movements, neutral movements) for the healthy controls in the regions that differed between high fear-avoidant and low fear-avoidant patients for all 3 groups; here it also becomes apparent that for all structures for which a difference between HFA and LFA was found, the similarities between high fear-avoidant participants and controls are high, with the low fear-avoidant participants showing the diverging pattern of activation.
      Instead of concentrating on the participants with HFA, perhaps we should examine more closely the participants who have experienced back pain, but report low fear avoidance. As is well known, they generally do better than persons with HFA in that they expect less pain when anticipating movements
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      and perform better in physical tasks.
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      • van Eek H.
      Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance.
      We suspect that the low fear-avoidant participants may use some kind of coping which enables them not to react with fear to potentially painful events, but to focus on other aspects. Perhaps they concentrate on the desired outcome and the benefit of the actions and activities, rather than any pain that might accompany it. This process may be adaptive or it may represent endurance behavior as hypothesized by Hasenbring.
      • Hasenbring M.I.
      • Hallner D.
      • Klasen B.
      • Streitlein-Böhme I.
      • Willburger R.
      • Rusche H.
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      • Hasenbring M.I.
      • Verbunt J.A.
      Fear-avoidance and endurance-related responses to pain: new models of behavior and their consequences for clinical practice.
      A similar interpretation was offered by Lloyd and colleagues, who proposed that well adjusted patients use top-down processes to achieve adjustment to the pain, for instance by distracting themselves from signals arising from the lower back.
      • Lloyd D.
      • Findlay G.
      • Roberts N.
      • Nurmiko T.
      Differences in low back pain behavior are reflected in the cerebral response to tactile stimulation of the lower back.
      The lingual gyrus also showed stronger activation in healthy controls relative to low fear-avoidant participants. To date, little is known about the functions of the lingual gyrus, especially with respect to pain research. As part of a visuospatial neural network it codes and stores environmental information,
      • Boccia M.
      • Nemmi F.
      • Guariglia C.
      Neuropsychology of environmental navigation in humans: Review and meta-analysis of fMRI studies in healthy participants.
      and is implicated in the early visual processing of threat-related information.
      • Larson C.
      • Aronoff J.
      • Sarinopoulos I.
      • Zhu D.
      Recognizing threat: A simple geometric shape activates neural circuitry for threat detection.
      • Maratos F.
      • Senior C.
      • Mogg K.
      • Bradley B.
      • Rippon G.
      Early gamma-band activity as a function of threat processing in the extrastriate visual cortex.
      Regarding its role in the present context one can only speculate: Perhaps it translates into a more intensive processing of the details of the possible threatening character of the back-straining movement scenes by the healthy controls compared with the low fear-avoidant participants, who may use strategies of avoiding such processing. However, this should be addressed in future research.

      Strength and Limitations

      The picture stimuli were carefully selected on the basis of pilot studies with back pain patients and healthy participants. The CLBP patients in our sample were severely affected: they had been suffering from moderate to strong pain (mean pain rating of 6) for a long time (over 12 years). The high fear-avoidant patients’ average TSK score was 39 points, which is well within the range of being commonly regarded as highly fear-avoidant.
      • Vlaeyen J.W.
      • Kole-Snijders A.M.
      • Boeren R.G.
      • van Eek H.
      Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance.
      • Vlaeyen J.W.
      • Kole-Snijders A.M.
      • Rotteveel A.M.
      • Ruesink R.
      • Heuts P.H.
      The role of fear of movement/(re)injury in pain disability.
      • Vlaeyen J.W.
      • Seelen H.A.
      • Peters M.L.
      • de Jong P.
      • Aretz E.
      • Beisiegel E.
      • Weber W.E.
      Fear of movement/(re)injury and muscular reactivity in chronic low back pain patients: An experimental investigation.
      However, limitations of the study were that the fear-avoidance of the healthy sample was not assessed and that the stimulus ratings were collected retrospectively after the scanning.
      Continuing the investigations of our previous study,
      • Barke A.
      • Baudewig J.
      • Schmidt-Samoa C.
      • Dechent P.
      • Kröner-Herwig B.
      Neural correlates of fear of movement in high and low fear-avoidant chronic low back pain patients: An event-related fMRI study.
      in which the participants may have passively viewed the back-straining movements, this time they were instructed to imagine that they themselves were carrying out the movement to engage their personal representations of the movements shown. However, although the participants have related the feared movements to themselves, the pictures may not have posed a threat to them because they knew that they would not have to perform the feared movements in reality.

      Conclusions

      On the basis of the FA model we expected to find fear-related neural activation in high fear-avoidant CLBP patients compared with low fear-avoidant CLBP patients and healthy controls when imagining back-straining movements. Indeed, high fear-avoidant patients showed stronger anterior hippocampus and middle temporal gyrus activation when imagining back-straining movements compared with low fear-avoidant patients, supporting the conclusion that fear-avoidance may have triggered representations related to pain expectancy to occur. However, healthy controls also had stronger hippocampus activation when contrasted with low fear-avoidant patients, contradicting an aspect of the FA model, which postulates that the movement–pain connections are learned in the acute phase of the back pain. We speculated that negative evaluations of the movement may have also been activated in healthy controls when they were confronted with back-straining movements. In contrast, the low fear-avoidant patients may have developed some kind of coping mechanism that enables them not to react with fear to back-straining movements.
      Research to date has concentrated mainly on high fear-avoidant patients because they were so adversely affected. Perhaps future research should place a stronger focus on low fear-avoidant patients and investigate what may enable them to not react with fear when faced with potentially painful movements.

      Acknowledgments

      The authors thank the following persons for their help: Ilona Pfahlert and Britta Perl, who conducted the MRI scans, Julia Glombiewski and Jens Tersek, who helped with the data collection in the pilot study for the selection of the movement stimuli, and Elisabeth Vögtle and Johanna König, who carried out SCID I interviews.

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