Mar 23, 2015

Applying Fear Avoidance to Athletes: The Athlete Fear Avoidance Questionnaire (AFAQ)

Greetings Readers! I am excited to share some new and important research with all of you. The Journal of Athletic Training (JAT) released a new study for early publication on March 20th, 2015 titled Development and Validation of the Athlete Fear Avoidance Questionnaire by Geoffrey Dover, PhD, CAT(C), ATC and Vanessa Amar, MSc, CAT(C) from Concordia University in Montreal, Quebec, Canada.

What is this and Why is it exciting?

The fear avoidance model and specifically tools like the Fear Avoidance Belief Questionnaire (aka the FABQ and it's derivatives) as well as the Pain Catastrophizing Scale (PCS) have been vital assets to the revolution of modern pain science, the ability to predict rehabilitation time lines, and for identifying individuals prone to exaggerated pain perception or with a high likelihood of developing chronic pain. 

While the fear-avoidance model definitely isn't brand new, this is an exciting study because it sets the groundwork to develop an FABQ equivalent for athletes. Specifically, the FABQ was developed, validated, and used for a general population. Despite it's success and the success of other items like the PCS when dealing with is NOT a perfect fit for use in an athletic population. I personally gave the FABQ to several athletes on several occasions and they would often become confused and disgruntled with the "work" related questions. This is where the AFAQ or Athlete Fear Avoidance Questionnaire could potentially come in handy.

Do you educate your patients on pain science? Are you even aware of the benefits of doing so?
-Photo Courtesy of Dr. Erson Religioso, PT of

What did they do?

The authors of this study assembled a squad of "experts" such as medical personal, sports psychologists, and sport coaches to develop a questionnaire using education on the fear-avoidance model, statistical methods developed for the creation of questionnaires, and the experience of the panel and their interaction with athletes and injuries.

The authors then took the AFAQ which underwent many revisions to its question and the scale system used for points until they were satisfied. Afterwords, they took the questionnaire and gave it to a variety of athletes (some healthy but previously injured and some with current injuries) to determine the correlation and thus validity of the new questionnaire compared with the previous but different FABQ and PCS questionnaires.

Here is the finalized AFAQ, courtesy of the Journal of Athletic Training.

What did they find out?

The authors were able to establish based upon their results that they had developed a questionnaire with both good internal and external validity, and that they had concurrent validity with both the FABQ (r=.352,p<.005) and the PCS (r=.587,p<.001). However, there was not a significant correlation between the work version of the FABQ (FABQ-W, r=.137, p=.176). This insignificance highlights the need for something like the AFAQ because it was hypothesized that the "work" related questions did not correlate or work well at all for athletes.

What should the take home point be?

I could write a conclusion for you all but I thought that they authors of this study did a great job of concluding this study in a very succinct manner. So I will let them take it away...

 "The AFAQ is a scale that measures injury–related fear avoidance in athletes. This scale could be used by sports medicine professionals, including athletic therapists and athletic trainers, as an extra rehabilitation tool to identify fear avoidance in athletes as a potential negative psychological barrier to rehabilitation. Fear-avoidance scales for the general population have already been used to predict return to work and the development of chronic pain. Similarly, identifying athletes with high levels of fear avoidance using a sport-specific scale could allow clinicians to address this psychological barrier early in rehabilitation and potentially reduce the time until return to play."

One last thing, in the discussion the authors are quick to take note but I wanted to make sure you all took this point home with you too before running off to use the AFAQ. This was an initial study that solely developed this new questionnaire and established it's validity with reference to the pre-existing FABQ and PCS.

There is still additional research needed on the AFAQ to see if it truly can be as essential and predictive as the aforementioned tools for the general population. Considering the positive correlations we can feel confident that it may but as always...we need some real evidence to be sure! However, pain science isn't just something for our "zebra" patients and is something that can be applied to everyone and that is why this is exciting. Being able to quantify emotions and beliefs related to pain and then educate our patients is a great step in the right direction for us to truly help them.

Feb 12, 2015

When Is Cryotherapy/Ice Supported By Research?

Howdy Readers! After yesterday's post ice seems to be a hot topic. I may have misled some of you yesterday with my thoughts on ice. Like many things in healthcare, science, and research the answers to questions are often shades of grey...not black and white like many would prefer. Therefore, today I wanted to share with all of you a guest post that I wrote for another website regarding a study that showcased a time when icing is warranted and was found to be very beneficial. This isn't the first article that shows evidence for this idea but it is the most recently published.

Additionally, I wanted to hammer home the idea that ice can still be used to modulate pain...if a 14 year old high school athlete suffers a severe ankle sprain for the first time and is in a lot of pain it would be unethical and unreasonable to deny him a bag of "ice" because research shows that it may not change blood flow. I can still help to modulate his pain without the use of narcotics or NSAIDs (a whole different bag of worms).

Nevertheless, pain should still be viewed as a perception and as something that can alter movement/motor control. We do not want to associate pain purely with structural damage because we know that is not the case based off the latest pain science. What I am against however is clinicians that ice to "treat" or "fix" injuries instead of using sound clinical reasoning, causative biomechanics, and taking pain science into consideration. We need to question the mechanism of why we are choosing a certain treatment, exercise, or modality. Enough with the ranting, here is my article!


A Novel Approach for Treating Arthrogenic Muscle Inhibition in Post-ACLR Patients?

Hart JM, Kuenze CM, Diduch DR and Ingersoll CD.J Athl Training. 49:6, 740-746.

How many of you have had the struggle of dealing with an ACLR patient that has suffered from an inability to regain full volitional control of their quadriceps group? This is a known pathology called Arthrogenic Muscle Inhibition (AMI) which has been defined in the literature as an inhibitory reflex in response to damage that has been suffered by the joint structures of the knee and it affects the musculature surrounding the knee. It is currently theorized in this condition that efferent input to the quadriceps has been inhibited in response to “aberrant” afferent input from the joint and the amount of motor units available for volitional control has been decreased.

            Initially, AMI may work as a protective reflex loop to protect the joint structures from further damage. However, in the scenario of an athlete that has undergone arthroscopic surgery to reconstruct an ACL injury it can be a burden that prevents a return to pre-injury levels of strength and side-to-side asymmetries. This condition would definitely be considered a detriment when it prevents our patients from receiving the entire benefits from their rehabilitation program and may wreak havoc upon their gait and other movement patterns.


What if this could be overcome with a simple and cost-effective intervention; perhaps an intervention as simple and globally available as applying an ice-bag prior to exercise intervention? Well that is exactly what this group of researchers did in this current study. Hart et al built upon previous research that showed that Hoffman reflex (h-reflex) could be increased when cryotherapy was used on subject’s with inhibited quadriceps due to knee-joints that had been artificially effused.

There is lot to discuss when it comes to the intricacies of methods and procedures for this study and the SMR already had a great post recently going over those details. You can read their take in more depth right here. On a global and applicable scale you may be wondering what they found out. Well let me cut to the chase; using a cryotherapy intervention immediately before performing rehabilitation exercises resulted in better quadriceps function and strength gains compared to the other interventions. This study was another brick laid for this theoretical foundation and it is forming quite nicely. However, there is still more research to do on this topic such as investigating other knee injuries like PFPS, patellar tendinopathy, meniscal injuries, and longer intervention trials >2 weeks are definitely warranted.

This study should be kept in mind that sometimes cryotherapy is warranted. Especially at a time when so many love to blindly point fingers at “passive modalities” such as cryotherapy. Anything can be the perfect intervention if applied in the right place, at the right time, and especially if it is guided by the right evidence. This is something to keep in mind the next time you find yourself struggling with a patient/athlete who is struggling to regain quadriceps function. It can’t hurt to try (unless they have a cold allergy), uses something that is most likely already located in your athletic training clinic, and has some promising research in the works.

Feb 11, 2015

New Research Continues to Support the Ending of an “Ice-Age”.

-Thanks for pic,

Hating on cryotherapy or “icing” musculoskeletal injuries seems to be the flavor of the month thing to do. Decades of conventional wisdom has told us that everything should be iced immediately after injury. RICE & PRICE were so-so nice we thought. However, when held under the light of scientific inquiry the evidence for cryotherapy was found to be on thin ice.

This blog post today isn’t going to be a rehash of previous arguments against cryotherapy. Here is a recent post by Josh Stone, MA, ATC where he gave his top 10 reasons to cease the cryotherapy craze. Instead, today I am going to discuss a recently published study on cryotherapy. This study by Selkow et al1 was just published early online by the Journal of Athletic Training. 

What did they investigate?

The authors wanted to investigate the effect of repeated cryotherapy treatments on microvascular perfusion after a bout of eccentric exercise. Why eccentric exercise? They did this because it has been previously shown in the literature that eccentric exercise results in increased blood flow just like the vasodilation associated with musculoskeletal injury. Therefore, this study would look directly at a very common clinical scenario (using cryotherapy on an acute episode of local inflammation.).

In this article the authors used a single-blind randomized controlled trial study design. They recruited 18 healthy subjects for this study and divided them into three separate groups (intervention, sham, and control.). If you are looking to find a good level of evidence when it comes to studies this is grade A stuff. The investigators were the ones blinded to the intervention not the subjects. I can imagine it would be difficult to blind a subject from whether or not they were receiving cryotherapy and that is why the authors didn’t use a double-blinded study design.

How did they investigate it?

The authors used microbubble infusion via an intravenous catheter that was measured using ultrasound imaging. This allowed the investigators to determine blood flow/local perfusion. After establishing a baseline, the subjects performed an eccentric exercise protocol. Within 1 minute of finishing the eccentrics the subjects were provided with the intervention (ice, sham, or control) depending on their random group allocation. 

After applying the intervention, perfusion was once again measured using the microbubbles and ultrasound. This began within 30seconds of completing the intervention. After this the participants returned 10, 24, and 48 hours after the initial intervention to reassess pain using a visual analog scale (VAS) before undergoing another intervention session (the same as the first, depending on their group placement). This closely mimicked what may be seen in an athletic training or by a person following traditional RICE advice at home.

Kind of like this...but not quite.

So What Did They Find Out?

The authors found out that there was NO difference in the amount of microvascular perfusion between the different intervention groups. This means a sham ice modality, doing nothing at all, and a bag of ice all had the exact same influence when it came to perfusion levels. In other words, the cryotherapy treatment was useless in terms of influencing perfusion. However, there was a difference between pain levels as assessed using the VAS. This was not much of a surprise considering cryotherapy has previously been noted for its ability to influence pain levels.

What does this all mean?

It is just another piece of evidence to support the idea that icing may not be doing what we thought it was doing. Specifically, cryotherapy does not seem to make a big difference in local blood flow after injury. Especially when considered in the light of an eccentric exercise model in this case. However, cryotherapy still remains a viable modality to alter pain perception within patients. While cryotherapy may not fix anything it may still be an option to modulate pain or suffering associated with experiencing a musculoskeletal injury.


I want people to realize that ice does currently have a time and a place. However, that place may not be where we once thought it was. Despite cryotherapy not changing bloodflow it does a great job of modulating pain. Additionally, cryotherapy has recently been found to be a great modality for treating arthrogenic muscle inhibition...Specifically in the quadriceps after knee injury. So ice is still cool for some mechanisms! Remember that! 

  1. Selkow, N. M., et al. (2015). "Blood Flow After Exercise-Induced Muscle Damage." J Athl Train.


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