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Purpose: Literature shows promising effects for interdisciplinary biopsychosocial rehabilitation programs in patients with chronic low back pain (CLBP). Not every patient needs an interdisciplinary rehabilitation trajectory provided in a secondary care setting. Patients with moderate complex psychosocial complaints might benefit from biopsychosocial interventions offered in primary care under supervision of a physician in rehabilitation medicine (i.e. biopsychosocial integrated care intervention). This study investigated the feasibility and effectiveness of such intervention in patients with CLBP with moderate complex psychosocial complaints. Methods: mixed-method. Patients (aged 18-65 years, low back pain ≥12 weeks, moderate complex psychosocial complaints) received the intervention (4 individual sessions, 8 group sessions) provided by trained primary care physiotherapists. Physicians in rehabilitation medicine provided one consultation afterwards. Data from patients (n¼18), physicians (n¼4) and physiotherapists (n¼12) were used. Results: Physiotherapists were satisfied with the training. Patient attendance was good for individual sessions, less for groups. Physiotherapists sufficiently delivered the intervention, although recruitment and contextual factors influenced delivery. Patients reported significantly reduced functional disability (Quebec Back Pain Disability Scale) post-treatment (-8.3, 95% CI -13.3 to -2.7) and at 3months follow-up (-7.6, 95% CI -12.9 to -2.2). Conclusions: A biopsychosocial integrated intervention is feasible and potentially effective in patients with CLBP. [ABSTRACT FROM AUTHOR]

To compare the effectiveness of a biopsychosocial primary care intervention (Back on Track) with primary care physiotherapy as usual in patients with chronic low back pain (CLBP) experiencing low complex psychosocial complaints. A double-blind multicentre pilot-randomised controlled trial. Twenty-five patients (≥18 years) with non-specific CLBP (≥12 weeks) experience low psychosocial complaints and a low to moderate level of disability. The Back on Track intervention (four individual and eight group sessions) versus physiotherapy as usual (maximally 12 individual sessions). Primary outcome: functional disability (Quebec Back Pain Disability Score) at post-treatment and 3 months follow-up. Anxiety, depression, catastrophizing, pain intensity, kinesiophobia, self-efficacy, global perceived effect. Effects were analysed using linear mixed model analysis. No significant differences in functional disability were found between interventions at post-treatment (mean difference 0.10, 95% CI: −12.9 to 13.1) and 3 months follow-up (mean difference −5.4, 95% CI −19.1 to 8.3). Secondary outcomes also showed no significant differences. No differences in effects were found between patients with CLBP experiencing low complex psychosocial complaints who receive the Back on Track intervention compared to patients receiving primary care physiotherapy as usual. Well-powered studies of sufficient methodological quality are needed to detect differences in effects. [ABSTRACT FROM AUTHOR]

Background and Objective: Recent systematic reviews show promising effects for multidisciplinary biopsychosocial (BPS) interventions in patients with chronic low back pain (CLBP). Nowadays, BPS interventions have also been developed for primary care physiotherapy settings. Our aim was to systematically review the evidence on the effectiveness of primary care BPS interventions in improving functional disability, pain, and work status for patients with CLBP. Secondly, we aimed to provide an elaborated overview of BPS intervention designs, physiotherapist training programs, and process‐related factors (practical implementation). Methods: We searched in scientific databases and reference lists. Randomized controlled trials (RCTs) evaluating primary care physiotherapist‐led BPS interventions in adults (≥18 years) with nonspecific CLBP (≥12 weeks) were included. Results: Our search resulted in 943 references; 7 RCTs were included (1,426 participants). Results show moderate‐quality evidence (3 trials; 991 participants) that a BPS intervention is more effective than education/advice for reducing disability and pain in the short, medium, and long term. Low‐quality evidence (4 trials; 435 participants) was found for no difference with physical activity treatments. Conclusions: BPS interventions seem more effective than education/advice and were found to be as effective as physical activity interventions in patients with CLBP. BPS interventions with a clear focus on psychosocial factors (understanding pain, unhelpful thoughts, coping styles, and goal setting) seem most promising. Sufficient delivery of BPS elements is expected when physiotherapists participate in training programs with extensive support prior and during delivery (manual, supervision, and informative resources). [ABSTRACT FROM AUTHOR]

Purpose: To summarize measurement instruments used to evaluate activity limitations and participation restrictions in patients with chronic fatigue syndrome (CFS) and review the psychometric properties of these instruments. Method: General information of all included measurement instruments was extracted. The methodological quality was evaluated using the COSMIN checklist. Results of the measurement properties were rated based on the quality criteria of Terwee et al. Finally, overall quality was defined per psychometric property and measurement instrument by use of the quality criteria by Schellingerhout et al. Results: A total of 68 articles were identified of which eight evaluated the psychometric properties of a measurement instrument assessing activity limitations and participation restrictions. One disease-specific and 37 generic measurement instruments were found. Limited evidence was found for the psychometric properties and clinical usability of these instruments. However, the CFS-activities and participation questionnaire (APQ) is a disease-specific instrument with moderate content and construct validity. Conclusion: The psychometric properties of the reviewed measurement instruments to evaluate activity limitations and participation restrictions are not sufficiently evaluated. Future research is needed to evaluate the psychometric properties of the measurement instruments, including the other properties of the CFS-APQ. If it is necessary to use a measurement instrument, the CFS-APQ is recommended. [ABSTRACT FROM AUTHOR]

A correction to the article "A biopsychosocial primary care intervention (Back on Track) versus primary care as usual in a subgroup of people with chronic low back pain: protocol for randomised, controlled trial" that was published in 2015 issue is presented.

Objective: To explore the ability of a self-report activity diary to measure the physical activity level (PAL) in female patients with chronic fatigue syndrome (CFS) and whether illness-related complaints, health-related quality of life domains (HRQOL) or demographic factors are associated with discrepancies between self-reported and objectively measured PAL., Methods: Sixty-six patients with CFS, recruited from the chronic fatigue clinic of a university hospital, and twenty matched healthy controls wore an accelerometer (Actical) for six consecutive days and registered their activities in an activity diary in the same period. Participants' demographic data was collected and all subjects completed the CFS Symptom List (illness-related complaints) daily and Short-Form-36 (HRQOL domains) during the first and second appointment., Results: A significant, but weak association between the activity diary and Actical was present in patients with CFS (r s  = 0.376 and r s  = 0.352; p < 0.001) and a moderately strong association in healthy controls (r s  = 0.605; and r s  = 0.644; p < 0.001) between week and weekend days, respectively. A linear mixed model identified a negative association between age and the discrepancy between the self-reported and objective measure of PA in both patients with CFS and healthy controls., Conclusion: The activity diary showed limited ability to register the PAL in female patients with CFS. The discrepancy between measures was not explained by illness-related complaints, HRQOL domains or demographic factors. The activity diary cannot replace objective activity monitoring measured with an accelerometer, but may provide additional information about the perceived activity., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: A significant proportion of adolescents with chronic musculoskeletal pain (CMP) experience difficulties in physical functioning, mood and social functioning, contributing to diminished quality of life. Generalized joint hypermobility (GJH) is a risk factor for developing CMP with a striking 35-48% of patients with CMP reporting GJH. In case GJH occurs with one or more musculoskeletal manifestations such as chronic pain, trauma, disturbed proprioception and joint instability, it is referred to as generalized hypermobility spectrum disorder (G-HSD). Similar characteristics have been reported in children and adolescents with the hypermobile Ehlers-Danlos Syndrome (hEDS). In the management of CMP, a biopsychosocial approach is recommended as several studies have confirmed the impact of psychosocial factors in the development and maintenance of CMP. The fear-avoidance model (FAM) is a cognitive-behavioural framework that describes the role of pain-related fear as a determinant of CMP-related disability., Content: Pubmed was used to identify existing relevant literature focussing on chronic musculoskeletal pain, generalized joint hypermobility, pain-related fear and disability. Relevant articles were cross-referenced to identify articles possibly missed during the primary screening. In this paper the current state of scientific evidence is presented for each individual component of the FAM in hypermobile adolescents with and without CMP. Based on this overview, the FAM is proposed explaining a possible underlying mechanism in the relations between GJH, pain-related fear and disability., Summary and Outlook: It is assumed that GJH seems to make you more vulnerable for injury and experiencing more frequent musculoskeletal pain. But in addition, a vulnerability for heightened pain-related fear is proposed as an underlying mechanism explaining the relationship between GJH and disability. Further scientific confirmation of this applied FAM is warranted to further unravel the underlying mechanism.In explaining disability in individuals with G-HSD/hEDS, it is important to focus on both the physical components related to joint hypermobility, in tandem with the psychological components such as pain-related fear, catastrophizing thoughts and generalized anxiety., (© 2020 Thijs van Meulenbroek et al., published by De Gruyter, Berlin/Boston.)

Background: To determine whether adolescents with generalized hypermobility spectrum disorder/ hypermobile Ehlers-Danlos syndrome (G-HSD/ hEDS) show changes in the level of disability, physical functioning, perceived harmfulness and pain intensity after completing multidisciplinary rehabilitation treatment., Methods: Pre-test post-test design. Fourteen adolescents with G-HSD/hEDS participated. The multidisciplinary rehabilitation treatment consisted of a combination of physical training and exposure in vivo . Physical training aims to improve aerobic capacity, muscle strength and propriocepsis for compensating hypermobility. Exposure in vivo aims to decrease disability and pain-related fear. Pre- and post-treatment assessments were conducted to assess the level of disability, physical functioning (motor performance, muscle strength and physical activity level), perceived harmfulness and pain intensity., Results: After completing multidisciplinary rehabilitation treatment, the adolescents showed a significant and clinically relevant improvement (improvement of 67%, p <0.01) in functional disability. Furthermore, significant improvements were found in motor performance ( p < 0.01), muscle strength ( p < 0.05), perceived harmfulness ( p < 0.01) and pain intensity ( p <0.01) after completing multidisciplinary rehabilitation treatment., Conclusion: Multidisciplinary rehabilitation treatment leads to a significantly and clinically relevant improvement in the level of disability for adolescents with G-HSD/hEDS. Positive effects were also found in physical functioning, perceived harmfulness and pain intensity. Although the results of this multidisciplinary rehabilitation treatment for adolescents with G-HSD/hEDS are promising, further study is needed to confirm these findings in a randomized design., Competing Interests: The authors have no conflicts of interest to declare., (Journal Compilation © 2020 Foundation of Rehabilitation Information.)

Background and Objective: The purpose of this study is to determine whether patients, classified by their treating consultant in rehabilitation medicine as avoider or persister, show differences in a large set of detailed outcomes of actual, objectively measured daily physical behaviour., Methods: In this explorative cross-sectional study, 16 patients were included; 9 patients were categorized as avoider and 7 patients as persister. Subjects wore the VitaMove activity monitor, a high-end accelerometry-based device that allowed automatic detection of a large set of body postures and motions. Physical behaviour was assessed in detail by total duration of body postures and motions as percentages of 24 hours, as well as by the number of sit-to-stand transfers, overall activity level, walking speed, and the distribution of bouts of physical activity and sedentary behaviour. Differences between groups were tested with the Mann Whitney U test., Results: There were no significant differences between groups in any of the physical behaviour outcomes., Conclusions: Our study showed that activity-related behavioural style categorization by consultants in rehabilitation medicine is not expressed in objectively measured detailed outcomes of daily physical behaviour.

Background The Photograph Series of Daily Activities-short electronic version (PHODA-SeV) assesses perceived harmfulness of daily activities in patients with low back pain (LBP). Although there is some evidence that the PHODA-SeV is a reliable and valid tool, its psychometric properties have not been fully investigated. Objectives To investigate the test-retest reliability, measurement error, interpretability, construct validity, and internal and external responsiveness of the PHODA-SeV in patients with chronic LBP. Methods Ninety-one patients were included in the analysis for this prospective cohort study. For reliability purposes, the PHODA-SeV was administered twice, with a 1-week interval before beginning treatment. Pain, disability, and measures of pain-related fear (ie, PHODA-SeV, Fear-Avoidance Beliefs Questionnaire [FABQ], and Tampa Scale of Kinesiophobia [TSK]) were collected before and after the 8-week treatment period. Results The PHODA-SeV showed excellent reliability (intraclass correlation coefficient model 2,1 = 0.91), without evidence of ceiling and floor effects. The construct validity analysis demonstrated fair correlations (r = 0.25-0.50) of the PHODA-SeV with the FABQ, but no correlation with the TSK (r<0.25). For internal responsiveness, the PHODA-SeV showed an effect size of 0.87 and a standardized response mean of 0.92, interpreted as a large effect (greater than 0.80). For external responsiveness, the correlations between the PHODA-SeV and changes in the TSK and FABQ were considered low, and the receiver operating characteristic curve analyses revealed an area under the curve lower than the proposed threshold of 0.70. Conclusion The PHODA-SeV is a reliable tool that can detect changes over time in pain-related fear in patients with chronic LBP undergoing physical therapy treatment. This tool, however, failed to identify those patients who did or did not improve, according to other pain-related fear measures. J Orthop Sports Phys Ther 2018;48(9):719-727. Epub 23 May 2018. doi:10.2519/jospt.2018.7864.

Study Design Cross-sectional study. Background Chronic musculoskeletal pain (CMP) has a negative impact on physical functioning. During adolescence, joint hypermobility is a potential risk factor for developing CMP, and pain-related fear contributes to the persistence of CMP. Whether pain-related fear and hypermobility are related, and even reinforce each other, resulting in a stronger association with perceived level of disability, is still unknown. Objectives To evaluate whether pain-related fear has a stronger association with disability in hypermobile compared to nonhypermobile adolescents with CMP. Methods The study included 116 adolescents with CMP. The presence of hypermobility was assessed using the Beighton score. Measures of pain intensity, age, sex, and pain-related fear were collected and included in the multivariable model. Hierarchical regression analysis, with disability as the dependent variable, was used to examine the interaction between hypermobility and pain-related fear. Results Hypermobile adolescents with CMP do not have more pain-related fear compared to nonhypermobile adolescents with CMP. There was no interaction effect between hypermobility and pain-related fear in explaining disability (β = .20, P = .42). Similarly, perceived harmfulness of balance-related activities was not more strongly associated with disability in hypermobile adolescents with CMP. Conclusion The association of pain-related fear with the perceived level of disability is not more pronounced in hypermobile compared to nonhypermobile adolescents with CMP. J Orthop Sports Phys Ther 2017;47(10):775-781. Epub 12 Sep 2017. doi:10.2519/jospt.2017.7282.

Introduction: Multidisciplinary biopsychosocial interventions are effective at improving functional disability in people with chronic low back pain. However, these interventions are often expensive and have long waiting times before treatment starts. Therefore, implementing biopsychosocial interventions in primary care settings may be of interest. Because people with chronic low back pain show different biopsychosocial profiles, they might respond differently to specific interventions., Research Questions: This study will investigate the difference in (cost) effectiveness between a biopsychosocial primary care intervention, Back on Track, and primary care physiotherapy as usual in a subgroup of adults with chronic low back pain., Design: Double-blind, multicentre (n = 8), randomised, controlled trial., Participants: Eighty-six adults with chronic low back pain, aged 18 to 65 years, experiencing low to moderate levels of disability and in whom the contributing role of psychosocial factors to this disability is restricted., Intervention: The Back on Track intervention: four individual and eight group sessions, based on biopsychosocial approaches from multidisciplinary pain rehabilitation programs and provided by trained physiotherapists., Control: Primary care physiotherapy as usual., Measurements: The primary outcome is functional disability (Quebec Back Pain Disability Scale) at post treatment, and 3-month and 12-month follow-up. Secondary measures are: credibility and expectancy, anxiety and depression, catastrophising, pain intensity, kinesiophobia, self-efficacy, participant's global perceived effect, cost-effectiveness, and cost-utility estimated with cost diaries and quality-adjusted life years., Analysis: Linear mixed models using an intention-to-treat principle. Incremental cost-effectiveness and cost-utility ratios will be calculated and plotted on a cost-effectiveness plane., Discussion: This study will provide useful information on a biopsychosocial intervention for chronic low back pain in primary care settings., (Copyright © 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Background Context: It has been controversially stated that pain-related fear is a more important determining factor for disability in chronic low back pain (CLBP) than pain or physical impairment in itself. So far, the relationship between psychological and physiological determinants of chronic pain, that is, pain-related fear and physiological abilities, remains unclear., Purpose: To evaluate whether pain-related fear assessed by different tools (both task specific and non task specific) is related to physical capacity measured by specific spine tests and, secondarily, to explore the relationship between different pain-related fear assessment tools., Study Design/setting: Cross-sectional study., Patient Sample: Fifty patients with CLBP (50% women; meanage [standard deviationage]: 44.2 [9.5 years])., Outcome Measures: Physical capacity by means of three specific spine tests, that is, the finger-floor distance test (flexibility), a maximal isometric strength test of trunk extensor muscles (strength), and the Sorensen test (endurance). Pain-related fear by means of self-report measures, that is, the Tampa Scale for Kinesiophobia (TSK), the Photograph Series of Daily Activities (PHODA), and a fear visual analog scale (FVAS) tailored to the spine tests., Methods: Participants were asked to complete the TSK and PHODA and to perform the three spine tests. Right before performing each of the spine tests, an FVAS was filled out. Linear regression analyses controlling for gender and age were performed to study the association between the pain-related fear measurements and the results of the spine tests. To investigate the relationship between the pain-related fear measurements, correlation tests were performed., Results: The linear regression analyses revealed that neither the TSK and PHODA scores nor the FVAS scores were significantly related to the physical capacity measurements. The correlational tests showed no significant correlation between the PHODA, TSK, and FVAS scores., Conclusions: The present study shows that neither the task-specific tool (FVAS) nor the non task-specific questionnaires (TSK and PHODA) were significantly correlated to the spine tests in patients with CLBP. This is contrary to earlier evidence according to which physical capacity is inversely related to the level of pain-related fear, and it suggests that one should not draw conclusions about physical capacity based on pain-related fear scores. Furthermore, the different assessment tools for pain-related fear were surprisingly not correlated with each other., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: According to the Cognitive behavioral therapy (CBT) protocol for patients with Chronic Fatigue Syndrome (CFS), therapists are advised to categorize patients in relatively active and passive patients. However, evidence to support the differences in physical functioning between these subgroups is limited. Using the baseline data from a multicentre randomized controlled trial (FatiGo), the differences in actual and perceived physical functioning between active and passive patients with CFS were evaluated., Methods: Sixty patients, who received CBT during the FatiGo trial were included. Based on the expert opinion and using the definitions of subgroups defined in the CBT protocols, the therapist categorized the patient. Data from an activity monitor was used to calculate actual physical functioning, physical activity, daily uptime, activity fluctuations and duration of rest during daily life. Perceived physical functioning was assessed by measuring physical activity, physical functioning and functional impairment with the Checklist Individual Strength, Short Form-36 and Sickness-Impact Profile 8., Results: Relatively active patients have a significantly higher daily uptime and show significantly less fluctuations in activities between days. Passive patients experience a significantly lower level of physical functioning and feel more functionally impaired in their mobility. However, no significant differences were found in the other actual or perceived physical functioning indices., Conclusions: A clear difference in actual and perceived physical functioning between relatively active and passive patients with CFS as judged by their therapists could not be found. Future research is needed to form a consensus on how to categorize subgroups of patients with CFS., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Unlabelled: Activity patterns are believed to play an important role in the development and perpetuation of chronic pain. So far, 3 important activity patterns have been studied: avoidance behavior, persistence behavior, and pacing behavior. Yet, empirical evidence is limited and inconclusive about the relationships between these activity patterns and important outcomes. Therefore, the present study was aimed at identifying activity patterns by means of factor analyses and determining their relationship with disability and depressive symptomatology in participants with chronic pain (N = 132). Items across different measurement instruments pertaining to 1 particular activity pattern were aggregated, and submitted to factor analysis. Results from 3 separate factor analyses revealed 6 distinct activity patterns: pain avoidance, activity avoidance, task-contingent persistence, excessive persistence, pain-contingent persistence, and pacing. In line with our hypotheses, pain and activity avoidance, and excessive persistence, were related to higher levels of disability and depressive symptomatology. In contrast to hypotheses, pacing was associated with worse outcomes as well. Interestingly, task-contingent persistence was related to lower levels of disability and depressive symptomatology. When controlling for pain and the other activity patterns, excessive persistence and activity avoidance were the most detrimental in terms of relations with depressed mood or disability. Task-contingent persistence appeared to be the least detrimental., Perspective: Our findings suggest the existence of several activity patterns, which are differentially related to disability and depressive symptomatology, in participants with chronic pain. The present results are discussed in the light of previous findings, and may provide a new impetus for future studies on activity patterns in chronic pain research., (Copyright © 2011 American Pain Society. Published by Elsevier Inc. All rights reserved.)

The aim of the present study was to compare the subjectively reported and objectively assessed activity-related characteristics of patients with Chronic Low Back Pain (CLBP) who were classified according to their scores on the Patterns of Activity Measure-Pain (POAM-P) into avoiders, persisters, mixed performers (i.e. high scores on both avoidance and persistence behaviour) or functional performers (i.e. low scores on avoidance and persistence behaviour). Patients carried an electronic diary during 14 days to assess the self-reported activity and pain intensity levels in daily life. An accelerometer was used to objectively assess their activity level during the same time period. Results were available for 79 patients. Avoiders, persisters and mixed performers showed a higher level of self-reported disability than functional performers. Avoiders were characterized by a low level of self-reported habitual activities and persisters by long objectively measured daily uptime. The objectively assessed level of physical activity did not differ between the four groups. A further analysis tested the association between pain intensity levels and self-reported and objectively assessed daily life activity levels in avoiders and persisters. In persisters, a higher level of self-reported activities in daily life was related to increased pain. The objectively assessed activity level was not associated with pain intensity., (Copyright © 2010 European Federation of International Association for the Study of Pain Chapters. Published by Elsevier Ltd. All rights reserved.)

In patients with low back pain (LBP), physical functioning may be negatively influenced by both expectations on pain and pain-related fear. It is unclear whether these factors influence both physical functioning in the laboratory as well as in daily life. The aim of this study was to test if a combination of persistent overprediction of pain and fear of movement predicts lab-based performance and whether these factors are relevant for predicting daily-life functioning. One hundred and twenty four patients with subacute LBP performed a laboratory-based performance test twice. Maximum voluntary contraction, pre-test pain expectations, perceived pain during testing and fear of movement were measured. Patients were classified as correct or incorrect predictors, based on differences between expected and perceived pain on the second attempt. Next, physical activity in daily life was measured with an accelerometer. In explaining physical functioning in the laboratory and in daily life an interaction effect between fear and pain prediction was observed. In overpredictors, fear was negatively associated with lab-based performance (beta=-0.48, p<0.01), and positively associated with daily-life functioning (beta=0.50, p<0.05). No significant association between fear and performance or daily-life functioning were found in correct predictors. In contrast to correct predictors, in overpredictors lab-based performance and daily-life functioning was additionally explained by fear of movement. Thus it appears that fear of movement is only predictive of performance in patients with LBP who simultaneously overpredict the consequences of movements in terms of painfulness., (Copyright (c) 2009 European Federation of International Association for the Study of Pain Chapters. Published by Elsevier Ltd. All rights reserved.)

Patients with chronic pain may have difficulties estimating their own physical activity level in daily life. Pain-related factors such as depression and pain intensity may affect a patients' ability to estimate their own daily life activity level. This study evaluates whether patients with Chronic Low Back Pain (CLBP) who are more depressed and/or report more pain indeed have a lower objectively assessed daily life activity level or whether they only perceive their activity level as lower. Patients with CLBP were included in a cross-sectional study. During 14days physical activity in daily life was measured, with both an electronic diary and an accelerometer. Multilevel analyses were performed to evaluate whether a higher level of depression and/or pain intensity was associated with a lower objectively assessed activity level or the discrepancy between the self-reported and objectively assessed daily life activity levels. Results, based on 66 patients with CLBP (mean RDQ score 11.8), showed that the objectively assessed daily life activity level is not associated with depression or pain intensity. There was a moderate association between the self-reported and objectively assessed activity levels (beta=0.39, p<0.01). The discrepancy between the two was significantly and negatively related to depression (beta=-0.19, p=0.01), indicating that patients who had higher levels of depression judged their own activity level to be relatively low compared to their objectively assessed activity level. Pain intensity was not associated with the perception of a patient's activity level (beta=0.12, ns)., (Copyright 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Patients with chronic low back pain (CLBP) often report a disabling decrease in their activity level due to pain. The nature of the association between disability, activity, and pain over time is however, unclear. An intriguing issue here is whether a high level of pain-related disability is associated with a low activity level or are changes in the level of activity over time pain provoking and thus more disabling? The objectives of this study were to investigate associations between disability, pain intensity, pain-related fear, and characteristics of physical activity in patients with CLBP. A total of 42 patients with CLBP were recruited from the Pain Clinic of the Maastricht University Hospital. Each pain patient carried an electronic diary for one week, in which questions about current pain intensity, and the level of physical activity were completed at 8 moments a day. Disability was scored by the Quebec Back Pain Disability Scale (QBPDS), Fear of movement by the Tampa Scale for Kinesiophobia (TSK). To explain the level of disability regression analyses were performed with disability as dependent variable and pain intensity, pain-related fear, and consecutively the level of physical activity in daily life and fluctuations in physical activity as independent variables. Results, based on 34 patients, showed that activity fluctuations (beta=0.373, p<0.05) rather than the mean activity level over time (beta=-0.052, ns) contributed significantly in explaining disability. The results are discussed in the light of current theories, previous research, and clinical implications.

Patients with musculoskeletal pain often report limitations in daily functioning due to pain. Recently, the World Health Organisation (WHO) recommended in their International Classification of Functioning, Disability and Health (ICF) to accentuate patients remaining possibilities in functioning instead of focussing on restrictions. In patients with musculoskeletal pain, this would imply that a person's "daily activity level" rather than his/her "disability level" has to be focussed upon. At this moment, broad consensus about how to measure physical activity in daily life in patients with pain has not been established. The objectives of this study were twofold, firstly to identify instruments assessing the level of physical activity in daily life in patients with musculoskeletal pain and secondly to review psychometric properties of the instruments identified. In all, 42 articles derived from the literature on musculoskeletal pain were included in the review. Thirty four assessment instruments for physical activity were identified; fourteen questionnaires, ten diaries and ten instruments based on movement registration. Only, 10 out of these 34 instruments contained full or partial information regarding pain specific psychometric properties. At this moment, for quantitative assessment of physical activity, movement registration seems to be favoured based on its higher degree of objectivity in comparison with self report. Taken together more research is needed to evaluate psychometric properties of instruments measuring physical activity in musculoskeletal pain.