Monday, March 23, 2009

Application of PSBI (Pain Belief Screening Instrument) in musculoskeletal pain disorders

Work of Lethem et al (2):

Lethem et al. introduced a so-called 'fear-avoidance' model to explain how and why some individuals with musculoskeletal pain develop a chronic pain syndrome. The central concept of their model is fear of pain. 'Confrontation' and 'avoidance' are postulated as the two extreme responses to this fear, of which the former leads to the reduction of fear over time. Off late a number of investigations have refined the fear-avoidance model.

Role of pain-related fear, and its immediate and long-term consequences in the initiation and maintenance of chronic pain disability:

1. The possible precursors of pain-related fear include the role negative appraisal of internal and external stimuli, negative affectivity and anxiety sensitivity.
2. A number of fear-related processes including escape and avoidance behaviors resulting in poor behavioral performance, hypervigilance to internal and external illness information, muscular reactivity, and physical disuse lead to de-conditioning and guarded movement.

Role of fear and avoidance in chronicity of musculoskeletal pain in primary health care:

Pain-related fear and avoidance appear to be an essential feature of the development of a chronic problem for a substantial number of patients with musculoskeletal pain (2). New emerging lines of investigation in chronic musclo-skeletal pain are related to information processing and anxiety sensitivity. These factors appear to be closely linked to pain-related avoidance behavior (1). Denison E et al explored the relations between disability, as measured by the Pain Disability Index (PDI) and self-efficacy, fear avoidance variables (kinesiophobia and catastrophizing), and pain intensity (3).

They found (3):
1. Self-efficacy beliefs are more important determinants of disability than fear avoidance beliefs in primary health care patients with musculoskeletal pain.
2. Pain-related beliefs, such as self-efficacy and fear avoidance, in turn, are more important determinants of disability than pain intensity and pain duration in these patients.
3. Gender, age, and pain duration were not related to disability.

Subgroups of Musculoskeletal pain in primary health care (4):

Denison E et al studied subgroup profiles based on self-reported pain intensity, disability, self-efficacy, fear of movement/(re)injury, and catastrophizing in patients with musculoskeletal pain.
While doing a cluster analysis to generate subgroups 3 subgroups were identified & these subgroups of patients with musculoskeletal pain present with different profiles in pain intensity, disability, and psychosocial variables.

The sub groups are:
1. "High self-efficacy-Low fear-avoidance,"
2. "Low self-efficacy-Low fear-avoidance," and
3. "Low self-efficacy-High fear-avoidance"

The subgroups differed significantly in work-status but not in age, gender, or duration of pain. It is further suggested that different management strategies may be relevant in each subgroup. & it is possible to tailor assessment and treatment approaches to each subgroup.

The pain belief screening instrument- PBSI (5):

The Pain Belief Screening Instrument (PBSI) covers pain intensity, disability, self-efficacy, fear avoidance and catastrophizing. Items for the Pain Belief Screening Instrument were derived from principal component analyses of: the Self-efficacy Scale, the Tampa Scale of Kinesiophobia and the Catastrophizing subscale in the Coping Strategies Questionnaire.

Sandborgh M et al worked to develop and test the ability of PBSI to identify subgroups among primary healthcare patients with musculoskeletal pain. PBSI identified 2 groups: high- or low-risk profile for pain-related disability.
Further Sandborgh M et al also found PBSI also can fairly well replicate subgroups. The reliability of items in the screening instrument was acceptable. However they suggested further testing of predictive validity of PBSI for primary healthcare population.

Predictive validity of PSBI for disability status in persistent musculoskeletal pain (6):
Predictive validity of the PBSI for disability was confirmed by Sandborgh M et al’s study (a prospective & correlational study). They also recommend clinical use the PBSI because it could serve as a mean to obtain supplementary and clinically useful information. In Sandborgh M et al’s study High-disability group had increased disability, unchanged pain intensity and decreased work capacity and daily function after 8 months & PSBI correctly classified 72% of the subjects as High-disabled or Low-disabled.

Locate the PSBI:

To know the items in PSBI down load the PDF file from this following link ( -) & then go to table no.3 on page 38 of the downloaded file.


1. Asmundson GJ et al; Clin Psychol Rev. 1999 Jan;19(1):97-119.
2. Vlaeyen JW et al; Pain. 2000 Apr;85(3):317-32.
3. Denison E et al; Pain. 2004 Oct;111(3):245-52.
4. Denison E et al; J Pain. 2007 Jan;8(1):67-74. Epub 2006 Sep 1.
5. Sandborgh M et al; J Rehabil Med. 2007 Jul;39(6):461-6.
6. Sandborgh M et al; Disabil Rehabil. 2008;30(15):1123-30.

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