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Table 4 Recommended observation methods suitable for utilization in clinical settings

From: How to objectively assess and observe maladaptive pain behaviors in clinical rehabilitation: a systematic search and review

Tool

Behavioral avoidance test (BAT-BACK) [27]

Pain Behaviour Scale [36]

What does the tool measure?

Measures observable avoidance behaviors. May be used to plan graded exposure for patients with chronic lumbar pain or as a tool to measure therapeutic success.

Measures observable pain behaviors.

How is the tool administered?

The patient must approach the feared stimulus in a standardized environment to induce fear and avoidance reactions

1. Instructions are given to the patient

2. Demonstration of movements (bending forward, lifting a box ~ 8 kg, rotation) by the evaluator

3. Movements are executed by the patient (10 repetitions)

4. Assessment of behavior (according to 3 categories)

The patient performs a standardized sequence of physical performance tests

1. Repeated trunk flexion

2. Repeated sit to stand

3. Timed up and go

4. Loaded reach

5. 50-ft walk

Observed PB

Category 1: The movement is carried out as demonstrated by the evaluator. No avoidance or protective behavior.

Category 2: The movement is carried out with protective behaviors (bended knees, keep the back straight by lifting or bending, move feet while turning, deep breaths, taking medication before the task, drinking water, seeking support, asking for help).

Category 3: The patient avoids making the movement. If less than 10 repetitions, missing repetitions are scored as avoided.

The specific pain behaviors assessed are:

- Sighing

- Breath-holding,

- Grimacing

- Guarding

- Rubbing

- Antalgic gait

Scoring and interpretation of the observation method

Each repetition is scored as follows:

Category 1 = 0 point

Category 2 = 1 point

Category 3 = 2 points

Thus, a score of 0 means that the patient avoided no movement or did not engage in a protective movement, and a score of 60 means that the patient avoided all movements.

For each task, the intensity and severity of PB are rated as below:

a) Intensity

Presence or absence of each PB

b) Severity

For each task, determination of PB severity with a 4-point scale:

0. None

1. Mild

2. Moderate

3. Severe

Finally, a total severity score (0–15) is obtained with the sum of the 5-task PB severity score.

Clinical benefits

• Easy to administer and interpret

• Short (approx. 5 min)

• Requires little to no material

• Easy to administer

• Short (10–15 min) and assess physical performance at the same time

• Requires little to no material

• Also informs on physical performance

Validity and Reliability

• The BAT-Back is a reliable and valid measure of pain avoidance behavior

Inter-rater reliability: good to excellent

• Internal consistency: excellent

• Convergent validity and divergent validity were determined

• Cross-cultural validity (Turkish) [40]

• The PaBS is a reliable and valid measure to assess the presence and severity of PB.

• Inter-rater reliability: excellent

• Intra-rater reliability: excellent

• Agreement for each PB in each task between 95 and 100%

• Perfect consistency for the absence/presence of PB

• Acceptable construct validity

Target population

People with chronic low back pain. (CLBP)

Participants in the validity study were between 18 and 65 years old.

People with chronic low back pain

Participants in this study were between 21 and 65 years old.