The Relationship between Fear-Avoidance Beliefs and Pain in Pregnant Women with Pelvic Girdle Pain: A Cross-Sectional Study.

BACKGROUND: Pelvic Girdle Pain (PGP) is one of the most common problems during pregnancy. Psychological variables including attitude, belief, cognition, and fear have more effects on risk factors for back pain, compared to biomechanical factors. Moreover, fear and anxiety may be provoked by the prospect of pain, which is associated with higher levels of disability, compared to pain itself. Therefore, this study aimed to investigate the relationship between fear-avoidance beliefs and pain in pregnant women with pelvic girdle pain.
METHODS: This descriptive cross-sectional study was conducted on 148 pregnant women with PGP, who referred to the healthcare centers affiliated to Shahid Beheshti University of Me-dical Sciences in Tehran, Iran from September to December 2017. The samples were selected by the multi-stage method. Data collection tools included a demographic questionnaire, Pelvic Girdle Questionnaire (PGQ) and Fear-Avoidance Beliefs Questionnaire (FABQ). Data analysis was performed in SPSS version 22, using descriptive statistics, ANOVA, t-test and multiple regression. A P-value less than 0.05 was considered significant.
RESULTS: The subjects' mean age and gestational age were 29.35±5.89 years and 32.78±5.13 weeks, respectively. Mean and SD of Fear-Avoidance Beliefs (FAB) toward PGQ was 41.27±13.67 (from 66). In addition, PGQ was moderate in the majority of participants [84 (56.75%)]. Results of one-way ANOVA demonstrated a significant relationship between the mean total score and the score of dimensions of physical and occupational activities of FAB in different severities of PGQ (P<0.001).
CONCLUSION: The results of this study indicated that fear-avoidance and catastrophic beliefs, in women with PGP can be predicted. According to the results of the study, FAB varied with the severity of pain. In addition, increased pain intensity was associated with elevated score of FAB.

INTRODUCTION

Lower back pain and/or Pelvic Girdle Pain (PGP) is the most common problem during pregnancy, the prevalence of which has been reported around 45%-78%.[1] PGP refers to pain in the symphysis pubis, between the iliac crest and gluteal fold, especially in the region of the sacroiliac joint.[2] Factors affecting the emergence of pain during pregnancy can be related to physiological and hormonal changes, stress, and lack of job satisfaction.[2] According to the literature, PGP may cause different degrees of disability.[3] In addition, this condition is observed in most societies and countries of the world; its common treatments include rest, avoidance of intense activities, physiotherapy, exercise therapy, acupuncture, various sports protocols during pregnancy, correct ergonomics, use of lumbar corsets, and in some cases, topical analgesic and anesthetic agents.[4]

On the other hand, diagnosis, determination of treatments with non-invasive methods and prevention of PGP before pregnancy seem necessary due to limitations in the assessment and treatment of this condition during pregnancy.[5] Therefore, both physical and mental dimensions must be considered to prevent the pain.[6] Repetitive relapses of pain and its significant psychological, environmental and social factors have turned it into a chronic and disabling condition.[7] Psychological variables, including attitude, belief, cognition, anxiety and concern, have more effects on the risk factors of back pain, compared to biomechanical factors.[8] Several psychological, social and cultural factors can play an effective role in the progression and persistence of pain syndromes and response to treatment.[9]

The initial response of a large number of individuals to low back pain is instinctively avoiding anything that is recognized as intensifier of back pain. However, fear of pain might cause constant avoidance of the mentioned situation after a while. While this type of behavior is somehow normal, it leads to an inadequate understanding of pain in some cases, provoking fear and anxiety, and finally leading to fear of moving and inability to perform daily, occupational and social activities.[10] According to some researchers, pain-related fear is more debilitating, compared to pain itself.[11]

The results of studies are contradictory. In a study, pregnant women with PGP had significantly higher levels of negative thoughts and Fear-Avoidance Beliefs (FAB).[12] In another study, there was a correlation between pain intensity, avoidance behavior and disability. A strong correlation was observed between pain and disability.[13] In a study, belief in avoiding fear and the number of pain sites were not significantly associated with the severity of disability or pain.[14] Also, in a study on patients with Low Back Pain )LBP(, there was no relationship among the Centre of Pressure measurements, fear of pain, and pain.[15] Results obtained in a study revealed that the influence of FAB on disability was minimal and much less than that of pain severity, and their contribution to the patient’s quality of life was irrelevant. Further studies should explore the potential value of FAB in other countries.[16] The relationship between pregnancy-related lumbar pain and its impact on women’s lives or the most effective strategies is still unclear. Catastrophic beliefs and fear avoidance in pregnant women with PGP have not been investigated.[12]

Fear is a more specific form of anxiety, which leads to a particular threat. In response to the fears caused by the great catastrophe and trying to control the painful event in future, patients are involved in avoiding and avoidance behaviors.[17]

Avoidance of fear is interpreted as escaping which leads to disruption of cognitive function and increased psychological responses. However, these reactions might be significantly more severe and cause a more serious condition in individuals with higher levels of fear.[18]

During pain, the patient seeks to escape the feeling of fear of pain. It is likely that the patient will become distressed in future when experiencing pain, resulting in avoidant behaviors. In any case, to stop the pain or avoid pain in the future, it is likely that the behavior is significantly changed. Escape and avoidance behaviors as a result of change in activity can lead to a three-dimensional disadvantage syndrome of disability, falling short of depression. It can be assumed that engaging in avoidance behaviors is the most important variable in predicting and determining whether a person will become disabled.[19]

With this background in mind, this study aimed to determine FAB toward PGP in pregnant women, who referred to the selected healthcare centers affiliated to Shahid Beheshti University of Medical Sciences in Tehran, Iran in 2017.

MATERIALS AND METHODS

This descriptive cross-sectional study was conducted on 148 pregnant women with PGP, who referred to the selected healthcare centers affiliated to Shahid Beheshti University of Medical Sciences in Tehran from September to December 2017.

Sample size was estimated at 148 individuals based on Olsson et al.’s study (2009)[12] and according to the prevalence formula and d=0.8, 95% confidence interval, P=44%. .

Subjects were selected through multi-stage sampling; one center from each of the five districts of Tehran was selected using the random number table and in proportion to the number of referrals for pregnancy cares. In addition, in each center women were selected through convenient sampling. Inclusion criteria were obtaining written informed consents from the subjects, gestational age of >20 weeks, diagnosis of PGP with Long Dorsal Sacroiliac Ligament (LDL) test, lack of underlying diseases, and no experience of intense stressful events during the past three months. Exclusion criterion was lack of willingness to continue participation in the research. Data collection tools were demographic characteristics questionnaire, Pelvic Girdle Questionnaire (PGQ), and Fear-Avoidance Beliefs Questionnaire (FABQ).

Demographic characteristics questionnaire: it includes gestational age, age, the spouse’s age , level of education, occupational status and types of parity.

Pelvic Girdle Questionnaire (PGQ): it has been designed by Stuge et al (2011), encompassing two subscales of activity and symptoms. The subscale of activity includes 20 items, whereas the subscale of symptoms has five items. In addition, the minimum score of activity and symptoms subscales were zero and the maximum score of activity and symptoms subscales was 60 and 15, respectively; also, the total score of the questionnaire was 75. Items were scored according to a four-point Likert scale. PGQ score less than 28 is mild, between 28 to 62 is moderate and more than 62 is severe. Evaluation of reliability and validity of the PGQ was performed by Stuge et al. (2011). Results were test-retest of reliability, including ICC: 0.93 (0.86-0.96) for the activity and 0.91 (0.84-0.95) for the symptom subscale.[20] Face and content validities were assessed according to the World Health Organization’s International Classification of Functioning, Disability and Health. Evaluation tools take three forms: a short version for screening/case-finding purposes; a version for daily use by care-givers; and a long version for detailed research purposes.[21] Rasch analysis was used for item reduction. Rasch model (χ2:8.00; P 0.63) indicated a unidimensional construct of the symptom subscale.[20] In the present study, the validity and reliability of pelvic pain questionnaire were evaluated. Content validity ratio was assessed 0.75-0.80 and content validity index was assessed 0.60-0.75. Exploratory factor analysis and Confirmatory factor analysis confirmed two-factors, that determined 70.22% of the variance. In the confirmatory factor analysis, the results of Chi-square test for Goodness of Fit were obtained firstly (df=274, χ2=1324.55, P<0.001). Other indicators were evaluated for fitting of the model. All indices, including NNFI=0.96, NFI=0.94, PNFI=0.86, CFI=0.96, IFI=0.96, RFI=0.94, confirmed the fitness for the final model. Also, the findings showed that internal consistency with Cronbach’s alpha was 0.96 (ranged from 0.87 to 0.91). The test-retest reliability with an ICC of 0.83.

LDL test: It is a diagnostic clinical test. The patient sleeps and lifts both the hip and knee joint slightly. The examiner is beside her and touches the sacroiliac joint. If the touch causes pain remaining after the removal of the examiner for more than five seconds, it will be considered as pain and if the pain disappears within 5 seconds, it will be recorded as tenderness. The sensitivity and specificity of this test for diagnosis of pelvic pain were 0.86 and 0.98, respectively.[22]

Fear-Avoidance Beliefs Questionnaire (FABQ): this 16-item questionnaire was scored according to the seven-point Likert scale, allocating zero and six scores to the alternatives of completely disagree and completely agree, respectively. The first two sections, or the physical section, consisted of five items evaluating pain-related avoidance behaviors toward physical activities. The second section contained 11 items, which assessed pain-related avoidance behaviors toward occupation. It is noteworthy that algebraic sum of four items (questions two to five) was provided to score the responses of the items in the physical section. In addition, minimum and maximum scores were zero and 24, respectively. Other items (1, 8, 13 and 16) were not regarded in scoring. In the second part, the answers to questions 6, 7, 9, 10, 11, 12 and 15 were summed algebraically, with a minimum score of zero and a maximum of 42. The total score of the questionnaire was a minimum of zero and a maximum of 66. The higher the score, the greater the avoidance perspective caused by pain. FABQ is a scale designed by Waddell et al. with an ICC of 0.74. Fear-avoidance beliefs about work and about physical activity using Cronbach’s alpha were 0.88 and 0.77, accounting for 43.7% and 16.5% of the total variance, respectively. Construct validity was assesd by factor analysis, confirming two dimensions for this questionnaire. The factor structure was explored using principal components analysis with varimax rotation. The items were accepted on the final factors if they had a loading of at least 0.45 on that factor and less than 0.30 on any other factor.[11]

Evaluation of reliability and validity of the FABQ was performed by Rostami et al. in Iran. Results were indicative of reliability, including ICC of 0.802-0.808, and internal consistency at the Cronbach’s alpha of 0.89. Exploratory factor Analysis determined two factor structures which could explain 57.9% of the total variance.[23]

Following the receipt of an introduction letter from Shahid Beheshti University of Medical Sciences and permission from the related healthcare centers, the eligible subjects were entered into the study after learning about the objectives of the research. At first, the diagnostic LDL test was performed on the participants, who referred to the selected healthcare centers, with the help of the researcher.

Examination was done in one of the rooms of the health center, in a quiet environment, away from other clients and staff, while explaning the process for participants with respect to privacy. The qestionnaires were filled out by the participants after confirming PGP. Our study did not have missing data.

Data analysis was performed in SPSS version 22, using descriptive statistics, one-way analysis of variance (ANOVA) and t-test. The descriptive statistics including frequency distribution, central indicators and dispersion including mean value and SD were used to describe demographic variables, level of education, types of parity, and occupational status. T-test was used to determine the relationship between primiparous and multiparous women in mean score of FAB.

One-way analysis of variance was used to find the relationship between the mean score of FAB in various intensity levels of PGP; also, to determine the factors predicting PGP, we used multiple regression analysis. In addition, a p-value less than 0.05 was considered significant. Ethics committee of Shahid Beheshti University of Medical Sciences approved the study with the code number of IR.SBMU.PHNM.1396.800.

RESULTS

In this research, the mean age of the subjects and that of their spouses were 29.35±5.89 and 34.30±6.20 years, and the gestational age was 32.78±5.13 weeks, respectively (Table 1). The mean score of FAB and PGQ was 41.27±13.67 and 39.72±19.33, respectively.

Table 1

Demographic characteristics of the participants

Demographic characteristics	N (%)
Level of education
Illiterate	2 (1.35)
Elementary	1 (0.67)
Junior high school	11 (7.44)
High school and diploma	58 (39.19)
Academic degree	76 (51.35)
Types of parity
Primiparous	87 (58.80)
Multiparous	61 (41.20)
Occupational status
Employed	94 (63.50)
Housewife	54 (36.50)

Mean physical, occupational and general scores of FAB were 16.58±5.29, 24.68±8.96 and 41.27±13.67, respectively. In general, PGQ was mild, moderate and severe in 46(31.08%), 84(56.75%) and 18(12.16%) of the subjects, respectively. In addition, results of one-way ANOVA demonstrated a statistically significant relationship between the mean score of FAB in various intensity levels of PGP (mild, moderate, severe) (Table 2).

Table 2

Mean score of fear-avoidance beliefs toward physical and occupational activities based on the Pelvic Girdle Questionnaire

FABa Dimensions	PGQb			P value*
	(Mild <28)	(Moderate=28-62)	(Severe >62)
	Mean±SD	Mean±SD	Mean±SD
Avoidance of physical activities	11.36±3.92	18.32±4.03	21.83±2.09	<0.001
Avoidance of occupational activities	17.30±5.37	26.67±8.22	34.27±4.81	<0.001
Total	28.67±8.61	45.00±11.52	56.11±6.41	<0.001

One-way ANOVA

Fear-avoidance beliefs

Pelvic girdle questionnaire

According to the results of t-test, a statistically significant relationship was observed between pregnant primiparous and multiparous women in terms of mean score of FAB toward PGQ (Table 3).

Table 3

Mean score of fear-avoidance beliefs toward Pelvic Girdle Questionnaire in participants according to the types of parity

FABa Dimension	Primiparous	Multiparous	P value*
	Mean±SD	Mean±SD
Avoidance of physical activities	15.66±5.54	17.90±4.64	0.01
Avoidance of occupational activities	23.45±8.68	26.44±9.12	0.04
Total	39.12±13.67	44.34±13.18	0.02

T-test

Fear-avoidance beliefs

The correlation between FAB and PGP scores remained consistent even when potential confounding factors (age, parity) were controlled. Two variables (age, parity) entered the regression, but the results of age variable was not statistically significant (P=0.789) and the only variable (parity) that was significant entered the table (Table 4).

Table 4

Adjusted correlation between fear-avoidance beliefs and Pelvic Girdle Questionnaire scores by controlling potential confounding factor

Model	B	R	R2	Std. Error	Beta	t	P-value*
FAB a	1.07	0.77	0.60	0.07	0.75	14.49		<0.001
Parity	2.49	0.78	0.61	1.17	0.11	2.12	0.03

Multiple Regression Analysis

Fear-avoidance beliefs

DISCUSSION

The present research was conducted in Iran for the first time to determine the FAB toward pain in various intensity levels in women with PGP. According to the results, FAB toward pain increased with elevated severity of PGP. In a study conducted on women with chronic low back pain in Isfahan, there was a positive and significant relationship between pain variables with anxiety, pain disaster and fear avoidance beliefs. However, among these three variables, fear avoidance beliefs showed a stronger relationship.[9]

Another study conducted on women in the 19-21th weeks of pregnancy in Stockholm revealed that pregnant women with lumbopelvic pain had higher levels of negative thoughts and FAB.[12] That is consistent with the results of the present study, indicating that women with chronic low back pain interpret chronic pain activities as a disgusting stimulus, so they refrain from these activities. Thus, the negative evaluation of an activity as a negative stimulus causes the patient to refuse to take into account the outcomes of the activity and the expectations about the pain of the movement. In this way, the positive and strong relationship between pain and these negative beliefs will explain the inability of the patient to be involved, consequently leading to inactivity.[9]

In a study conducted on Saudi women with chronic low back pain, there was a positive and significant relationship between disability with physical activity and work, confirming the relationship between low back pain-related disability with fear avoidance beliefs.[24]

Although the tools used to measure the disability of the patient in this study and those of our study are different, the results of these two studies are consistent. In a recent study, self-reported questionnaire was used to measure disability, so participants may indicate the degree of pain and disability which makes it different from the actual pain and disability, and this may be a significant cause of the relationship between the two belief variables due to fear and disability caused by pain.

Another study, conducted on patients with low back pain, showed that there was a significant correlation within Fear-Avoidance Beliefs Questionnaire for Physical Activity (FABQ-PA) with Roland Morris Disability Questionnaire ( RMDQ).25 These results are consistent with those of our study. Perhaps, the reason for this similarity is that the presence of back pain was confirmed by an expert (not commenting on the presence of low back pain by the patient without a doctor’s or expert’s examination).

Also, in a study conducted on patients with low back pain, a significant correlation was not found between the results of FABQ-PA and MODQ. This discrepancy with the results of the present study might be due to differences in the collection tools, the age range of the participants, and the gender of the participants. Also, a self-report questionnaire was used to measure incapacity, so the participants may indicate the degree of pain-related disability different from actual pain and disability.[26]

In a study conducted in Denmark on patients with LBP there was no relationship among the centre of pressure measurements, fear of pain, and pain.[15] In another study conducted on women from early to late pregnancy, belief in avoiding fear and the number of pain sites were not significantly associated with severity of disability or pain.[14] This is not consistent with the results of the present study. The reason for this inconsistency may be the difference in the type of study, different age ranges of pregnancy during the measurement of pain and disability, and the measurement difference.

In several studies, it has been shown that fear of displacement depends on compensation status and depression. In addition, people who report high degrees of fear of displacement of injury have more fear and avoidance when faced with a simple movement. This focused on the clinical relevance of the structure of fear of injury.[27,28] There are numerous mechanisms showing that the fear of pain can lead to inability to move; they include attention to pain, and catastrophic view about it. Fear of avoidance behavior is the immediate consequence that will cause the person not to perform daily activities. Avoidance of daily activities impairs one’s performance.[29,30]Avoidance of fear is interpreted as escaping from a condition that might be associated with pain, leading to disruption of cognitive function and increased psychological responses. However, these reactions might be significantly more severe and cause a more serious condition in individuals with higher levels of fear. In general, fear affects the reaction to and evaluation of pain.[18]

According to the results of the current study, FAB was significantly more observed in multiparous women, compared to primiparous subjects. The number of deliveries and experience of back or hip pain in the previous pregnancy are among the risk factors for back pain during pregnancy.[31] Multiparous women with low back or hip pain have possibly experienced previous pain.[32] It has been reported that previous negative experience leads to fear and avoidance. In addition, pain-related negative beliefs cause negative emotions and change the level of pain tolerance, increasing the possibility of the occurrence of more severe outcomes, physical inabilities, and fear and creating the foundation for anxiety and formation of fear-avoidance behaviors.[28,33,34] On the other hand, women avoid re-experiencing traumatic events and conditions.[35]

The strengths of this study were the diagnosis of pelvic girdle pain with clinical diagnostic test (ligament Long dorsal sacroiliac), as well as subjective pelvic girdle pain questionnaire.

One of the major limitations of the present research was lack of considering the role of other effective factors such as depression and anxiety in this area.

CONCLUSION

The results of this study indicated that fear-avoidance and catastrophic beliefs, in women with PGP could be predicted. According to the results of the study, FAB varied with the severity of pain. In addition, increased pain intensity was associated with increased score of FAB. It is suggested that further studies should be conducted on the outcomes and consequences of FAB in women with PGP during and after pregnancy.