Criterion Validity of a Single-Item Measure of Fear Avoidance Behavior Following Mild Traumatic Brain Injury

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Silverberg This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3977522/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Sep, 2024 Read the published version in BMC Neurology → Version 1 posted 9 You are reading this latest preprint version Abstract Maladaptive coping such as fear avoidance behavior can prolong recovery from mild traumatic brain injury (mTBI). Routine assessment of fear avoidance may improve management of mTBI. This study aimed to validate a single-item measure of fear avoidance to make its assessment more pragmatic. The present study is a secondary analysis of a clinical trial that involved adults with persistent post-concussion symptoms (N = 90, 63% female). Participants completed the single-item fear avoidance rating, a validated legacy measure of fear avoidance (Fear Avoidance Behavior after Traumatic Brain Injury; FAB-TBI), and measures of anxiety (General Anxiety Disorder-7), depression (Patient Health Questionnaire-9), post-concussion symptoms (Rivermead Postconcussion Symptoms Questionnaire), and disability (World Health Organization Disability Assessment Schedule 12.0). Questionnaires were completed twice, at baseline (mean 18.1 weeks post injury) and again 12–16 weeks later following study-delivered rehabilitation in addition to usual care. We analyzed the associations (Spearman’s correlations) and agreement (Bland-Altman plots) between the single-item and FAB-TBI at baseline, posttreatment, and the change in scores between baseline and posttreatment. In addition, we examined correlations between the single-item avoidance scale and related constructs, including anxiety, depression, post-concussion symptoms, and disability. The single-item fear avoidance measure correlated strongly with the FAB-TBI both at baseline and following treatment ( ρ = .63 − .67, p < .001). The correlation between the change in these scores from baseline to posttreatment was moderate ( ρ = .45, p < .001). Before and after treatment, the single-item fear avoidance measure correlated moderately with anxiety ( ρ = .34), depression ( ρ = .43), post-concussion symptoms ( ρ = .50), and disability ( ρ = .43). The FAB-TBI was more strongly correlated with these measures ( ρ = .53 − .73). In summary, the present study supports the criterion validity of the single-item fear avoidance measure. This measure may be a useful screening and monitoring tool for patients with mTBI but is not a substitute for the FAB-TBI questionnaire. fear avoidance mTBI outcome measures psychometrics Figures Figure 1 Introduction Every year, 50–60 million people sustain a traumatic brain injury worldwide and 80–90% of TBIs are classified as mild [ 1 ]. At least 20% of adults with mild TBI experience persistent post-concussion symptoms, such as headaches, memory problems, and fatigue [ 2 ]. Maladaptive coping with post-concussion symptoms can hinder recovery from mild TBI. Perhaps the best studied maladaptive coping style after mild TBI to date is fear avoidance behavior. Fear avoidance refers to avoiding or escaping from activities and situations that the injured person expects might aggravate their symptoms or result in other harms (e.g., re-injury, social embarrassment, etc.). Prolonged fear avoidance is associated with worse post-concussion symptoms and disability [ 3 – 6 ], heightened sensitivity to symptom provocation [ 7 – 8 ], and lower rates of return to work [ 9 ]. Targeting fear avoidance psychologically-informed rehabilitation may improve mild TBI outcomes [ 10 ]. Most prior studies have measured fear avoidance behavior after mild TBI with the 16-item Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI) [ 11 ]. This scale was adapted from existing measures of fear avoidance in the chronic pain literature. The FAB-TBI has high internal consistency and acceptable unidimensionality [ 11 ], and clinical reference values are available [ 3 ]. With 16 items, the FAB-TBI is somewhat lengthy, which can be prohibitive for regular use in clinical settings and in research studies where fear avoidance may be relevant, but is not of primary interest. An ultra-brief fear avoidance scale would allow for more widespread measurement of this important construct. Single-item measures of psychological constructs can be reliable and valid [ 12 – 14 ]. The present study aimed to evaluate a single-item measure of fear avoidance. A single-item fear avoidance scale could be useful for screening, serial monitoring, and for ecological momentary assessment, which involve intensive repeated measurements [ 15 ]. Aims This study aims to investigate the criterion validity of a brief, single-item measure of avoidance following mild TBI. We report the association and agreement between the single-item fear avoidance measure and the legacy FAB-TBI scale. We further examined associations between the single-item fear avoidance measure and clinical outcomes that are correlated with fear avoidance as measured by the FAB-TBI [ 11 ], including depression, anxiety, post-concussion symptoms, and disability. Methods Study population This is a secondary analysis of a randomized controlled trial investigating the feasibility of two behavioral interventions following concussion [ 10 ]. The study was approved by the Clinical Research Ethics Board at the University of British Columbia (H18-02344). Detailed methods for the parent study are reported elsewhere [ 10 ]. The sample was comprised of N = 90 adults (< 70 years old) who were recruited from two concussion clinics in British Columbia, Canada and sustained an mTBI between 1–12 months prior. Eligible participants had persistent, moderate to severe post-concussion symptoms as measured by the Rivermead Postconcussion Symptom Questionnaire [ 16 ], and high avoidance and/or endurance behavior [ 10 ]. Participants completed questionnaires twice: once at clinic intake (M = 18.2 weeks post injury) and again 12–16 weeks later (M = 32.2 weeks post injury, n = 82) following treatment. Treatments targeted two different coping styles: fear avoidance (graded exposure therapy) or endurance behavior (operant conditioning-based pacing and mindfulness training) [ 10 ], and were delivered via videoconference over the span of eight weeks. All participants had unrestricted access to usual care. Information about participant demographics and injury mechanism were collected at baseline. Ninety participants completed both the single-item fear avoidance measure and FAB-TBI at baseline/pre-treatment, and 82 of these participants also completed both measures post-treatment. Measures Single-Item Fear Avoidance Measure Participants were asked how strongly they agree with the following statement “ I avoid activities that might make my symptoms worse ” over the past week, on a 10-point Likert scale from 1 ( Strongly disagree ) to 10 ( Strongly agree ). Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI) The FAB-TBI is a validated 16 item self-report scale [ 11 ]. Items are assessed on a scale of 0 ( Strongly disagree ) to 3 ( Strongly agree ), where high scores indicate greater fear avoidance behavior. It includes items that reflect cogniphobia (e.g., “ I worry that when I have to think or concentrate too hard that I will bring on a headache ”) and general activity avoidance (e.g., “ I have avoided my usual activities ”). Raw scores are converted into Rasch scores to convert ordinal scores to a linear scale [ 11 ]. Patient Health Questionnaire 9 (PHQ-9) The PHQ-9 is a nine-item self-report measure of depression symptom severity [ 17 ]. Each of the items corresponds to one of the criteria that assesses depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), where scores are assessed from 0 ( Not at all ) to 3 ( Nearly every day ). The total score is the sum of all the individual items. The PHQ-9 has demonstrated excellent internal reliability (Cronbach’s α = 0.89) and test-retest reliability and is a valid measure of depression severity [ 17 ]. General Anxiety Questionnaire 7 (GAD-7) The GAD-7 is a seven-item self-report measure of generalized anxiety [ 18 ]. Items are assessed on a four-point rating scale ranging from 0 ( Not at all ) to 4 ( Nearly every day ). The total score of the GAD-7 is the sum of the scores on the 7 items. The GAD-7 has good test-retest reliability, construct validity, and criterion validity, and excellent internal consistency (Cronbach α = .92). World Health Organization Disability Assessment (WHODAS) World Health Organization Disability Assessment Schedule 2.0 12-item interviewer version assesses functioning across six domains of the International Classification of Disability, Functioning, and Health [ 19 ]: cognition, mobility, self-care, interpersonal functioning, life activities, and participation. The WHODAS demonstrates high internal consistency (Cronbach’s α = .86) and excellent test-retest reliability in a general population. The WHODAS has also been evaluated in a mild TBI sample, where it showed high internal consistency (Cronbach’s α = .92) and adequate construct and concurrent validity [ 20 ]. A Rasch transformation to WHODAS scores was applied to enhance psychometric properties in a mTBI sample, using ordinal to interval score conversions [ 20 ]. Rivermead Postconcussion Symptoms Questionnaire (RPQ) The RPQ is a 16-item self-report scale that assesses symptom severity following mTBI [ 16 ]. Participants were asked to compare their symptoms in the past 24 hours to prior to their injury on a scale from 0 ( Not experienced at all ) to 4 ( A severe problem ). Some symptoms assessed by the RPQ include headaches, dizziness, nausea, sleep disturbances, fatigue, and concentration problems. The total score is the sum of all the individual items with 1 (“no more of a problem”) recoded as 0. Statistical analyses Information about participant demographics and injury characteristics were described in terms of mean, standard deviation, and frequency. To assess the criterion validity of the single-item measure of fear avoidance, we examined its correlation and agreement with the 16-item FAB-TBI. Bland-Altman plots were used to explore the agreement between the single-item measure of fear avoidance and FAB-TBI at baseline, posttreatment, and the change in scores between baseline and posttreatment. Values of the single-item avoidance measure and FAB-TBI were standardized, by subtracting each participant’s score from the mean of the total sample, then dividing that value by the standard deviation of the sample. Each point in the scatterplot represents a participant, where the X-axis represents the average score of the single-item measure and FAB-TBI, and the Y-axis represents the difference in standardized scores between the two measures of fear avoidance. Change in scores was calculated by subtracting scores at baseline from the scores posttreatment [(score posttreatment) – (score at baseline)], for both the single-item measure and FAB-TBI. Data points clustering close to the horizontal midpoint indicate high agreement, whereas greater dispersion signifies lower levels of agreement [ 22 ]. The limits of agreement were derived by calculating the mean difference between the measurements, and then establishing the 95% confidence interval around the mean difference by subtracting +/- 1.96 multiplied by the standard deviation of the difference. Scores above the 2.5th and below the 97.5th percentile fall within the limits of agreement [ 22 , 23 ]. The convergent validity of the single-item measure of fear avoidance was assessed using correlation with related measures, including post-concussion symptoms (RPQ) [ 16 ], depression (PHQ-9) [ 17 ], anxiety (GAD-7) [ 18 ], and disability outcomes (WHODAS) [ 19 ]. In addition, we calculated the correlation between change in single-item and FAB-TBI scores before and after treatment. Spearman’s rank correlation coefficient ( ρ ) was used due to the non-normal distribution of single-item avoidance scale scores (Appendix 1a, 1b) and monotonic relationship between single item and other measures. To facilitate comparisons, we report Spearman’s ρ for all other correlations. Statistical analyses were conducted using R version 1.4.1103 and SPSS version 27. Results The current study included N = 90 participants at baseline and n = 82 participants posttreatment. Of the eight participants that did not complete their assessment post-treatment, two participants (n = 2) withdrew from the study and six (n = 6) participants did not complete their outcome assessment following treatment. The majority of included participants were women (63.3%) and White (75.6%). The median age of the sample was 40.5 years (range = 20-65). See Table 1 for full demographic and injury characteristics. Descriptive statistics for the full sample are shown in Table 2. In terms of single-item avoidance scale scores at baseline/pre-treatment, the median score was 6 (Q1- Q3: 3-8). Posttreatment, the median score was 3 (Q1- Q3: 1.25-6). The total score of the single-item measure of fear avoidance showed minimal floor (7.8%, n = 7) and ceiling effects (14.4%, n = 13) at baseline. At follow up, a greater percentage demonstrated floor levels (23.3%, n = 21), however the ceiling effects were diminished (3.7%, n = 3). Frequency distributions for single-item avoidance scale (Appendix 1a, 1b) and the FAB-TBI (Appendix 2a, 2b) are available in the supplementary materials. FAB-TBI scores demonstrate a normal, unimodal distribution both at baseline (Appendix 2a) and following treatment (Appendix 2b). Scores for both FAB-TBI and the single-item measure of fear avoidance decreased on average following treatment, as expected, as treatments aimed to reduce fear avoidance behavior (Appendix 1, Appendix 2). Table 1 Participant demographic and clinical characteristics (N=90) Variable Value Age, Mean (SD), 41.59 (11.1) Sex, n (% female) 57 (63.3%) Ethnicity, n (%) White Asian Middle Eastern African Indigenous Hispanic 67 (75.6%) 15 (16.5%) 5 (5.5%) 1 (1.1%) 1 (1.1%) 1 (1.1%) Years Education, M (SD) 15.46 (2.31) Mechanism of Injury, n (%) Moving head Whiplash no contact Moving object 63 (70.0%) 18 (20.0%) 9 (10.0%) LOC, n (%) Yes Suspected No Unknown 11 (12.2%) 10 (11.1%) 62 (68.9%) 5 (5.6%) PTA, n (%) Yes No Unknown 43 (47.8%) 46 (51.1%) 1 (1.1%) Confusion Yes No Unknown 84 (93.3%) 4 (4.4%) 1 (1.1%) Note . M = Mean, SD = Standard Deviation, LOC = Loss of consciousness; PTA = post-traumatic amnesia. Table 2 Descriptive statistics of psychological self-report measures Scale Baseline Posttreatment Mean (SD) Min - Max Mean (SD) Min - Max Single-item fear avoidance 5.8 (2.87) 1 - 10 3.9 (2.72) 1 - 10 FAB-TBI Rasch 23.7 (7.23) 6.05 - 48.0 18.2 (6.89) 0 - 34.9 GAD-7 9.2 (5.15) 0 - 21 5.8 (5.88) 0 - 21 PHQ-9 12.4 (5.70) 1 - 27 7.7 (5.79) 0 - 26 WHODAS Rasch 19.8 (3.90) 10.09 - 27.90 14.3 (5.74) 0 - 26.26 RPQ baseline 33.9 (14.41) 0 - 61 22.9 (14.82) 0 - 54 Note. FAB-TBI = Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire GAD-7 = General Anxiety Questionnaire 7 PHQ-9 = Patient Health Questionnaire WHODAS = World Health Organization Disability Assessment RPQ = Rivermead Postconcussion Symptoms Questionnaire SD = Standard Deviation At baseline, a moderately strong positive correlation was observed between the single-item fear avoidance measure and FAB-TBI ( ρ = .67, p < .001) The single-item fear avoidance measure correlated moderately with anxiety (GAD-7; ρ = .34, p < .001), depression (PHQ-9; ρ = .43, p < .001), post-concussion symptoms (RPQ; ρ = .50, p < .001), and disability (WHODAS; ρ = .43, p < .001). The FAB-TBI was more strongly correlated with these measures: anxiety ( ρ = .53; p < .001), depression ( ρ = .71; p < .001), post-concussion symptoms ( ρ = .73; p < .001) and disability ( ρ = .66; p < .001). Posttreatment, there was a moderate correlation between the single-item fear avoidance measure and FAB-TBI ( ρ = .63, p < .001). Following treatment, the single-item fear avoidance measure correlated moderately with anxiety (GAD-7; ρ = .38, p < .001), depression (PHQ-9; ρ = .47, p < .001), post-concussion symptoms (RPQ; ρ = .53, p < .001), and disability (WHODAS; ρ = .53, p < .001). Again, the FAB-TBI was more strongly correlated with these measures: anxiety ( ρ = .59; p < .001), depression ( ρ = .64; p < .001), post-concussion symptoms ( ρ = .72; p < .001) and disability ( ρ = .71; p < .001). The correlation between the change scores from baseline to posttreatment for the single-item fear avoidance measure and FAB-TBI was moderate ( ρ = .45, p < .001). Inspection of the Bland-Altman plots suggested moderate agreement between the single-item fear avoidance measure and FAB-TBI both before (Figure 1) and after (Figure 2) treatment. At both baseline and posttreatment, most values were inside the limits of agreement. A mean standardized difference of -0.02 (-1.66, 1.62) was observed between the single-item fear avoidance measure and FAB-TBI at baseline, indicating that the single-item measure did not systematically under- or overestimate FAB-TBI scores. The mean standardized difference following treatment was .78 (-1.04, 2.62), indicating that participants tended to score slightly lower on the single-item fear avoidance measure as compared to FAB-TBI, however this difference is negligible. Posttreatment, participants scored higher on the single-item measure as compared to FAB-TBI. There was a negligible difference between the standardized change scores [.01 (-2.15, 2.16)], indicating that there is high agreement between in the change in standardized scores from baseline to posttreatment. In addition, the relatively symmetrical distribution of difference scores further supports the agreement of the change scores. Figure 1a Bland-Altman Plot Exploring Agreement Between Single-Item and FAB-TBI at Baseline Figure 1b Bland-Altman Plot Exploring Agreement Between Single-Item and FAB-TBI Posttreatment Note. Figures 1a and 1b represent the Bland-Altman plots of the total standardized scores of the single-item measure of fear avoidance and FAB-TBI at baseline and posttreatment, respectively. Standardization involved subtracting the mean from the total score, and dividing by the standard deviation (sd), or [(value – mean)/sd]. The X axis represents the average of the single-item measure of fear avoidance and FAB-TBI, or [(single-item + FAB-TBI)/2]. The Y axis represents the difference between the single-item measure of fear avoidance and FAB-TBI, or single-item minus FAB-TBI. Positive Y axis values indicate that standardized scores in the single-item measure of fear avoidance are greater than standardized FAB-TBI scores. Negative values on the Y axis indicate that standardized FAB-TBI scores were greater than the standardized single-item scores. The dotted lines display the 95% limits of agreement, and the dashed line represents the mean difference. Figure 1c Bland-Altman Plot Exploring Agreement Between Change in Scores between Baseline and Posttreatment in the Single-Item and FAB-TBI Note. Figure 1c represents the change in total standardized scores of the single-item measure of fear avoidance and FAB-TBI between baseline and posttreatment. The change in scores was calculated by subtracting scores at baseline from the scores posttreatment [(score posttreatment) – (score at baseline)], for both the single-item measure and FAB-TBI. The X axis represents the change in the average score of both the single-item measure of fear avoidance and FAB-TBI, or [(change score of single-item + change score of FAB-TBI)/2]. The Y axis represents the difference between the change in scores between baseline and posttreatment in the single-item measure of fear avoidance and FAB-TBI, or [(change score of single-item - change score of FAB-TBI). Positive Y axis values indicate that standardized scores in the single-item measure of fear avoidance are greater than standardized FAB-TBI scores. Negative values on the Y axis indicate that standardized FAB-TBI scores were greater than the standardized single-item scores. The dotted lines display the 95% limits of agreement, and the dashed line represents the mean difference. Discussion The present study examined the criterion validity of a single-item measure of fear avoidance after mild TBI. We observed a moderately strong positive correlation between the single-item fear avoidance measure and FAB-TBI at baseline, indicating that these two scales may measure the same construct, or at least that there is overlap in what they measure. The strength of these correlations ( ρ = .67 at baseline and ρ = .63 post treatment) approached the benchmark of > .70 suggested by previous studies as indicator of criterion validity of a single-item scale [ 13 , 14 , 23 , 24 ]. Additionally, the correlation between the change in scores from baseline to posttreatment between the single-item and FAB-TBI was moderate ( ρ = .45, p < .001). The single-item of fear avoidance demonstrated adequate convergent validity by correlating with measures of anxiety, depression, post-concussion symptoms, and disability. However, correlations between the single-item measure of fear avoidance and related constructs were somewhat weaker than the correlations between FAB-TBI and related constructs. The stronger associations may be explained by the fact that FAB-TBI is a multi-item measure of fear avoidance, and is better able to capture a broader range of fear avoidance behavior. The single-item fear avoidance measure did not systematically under- or over-estimate FAB-TBI scores. The Bland-Altman analyses revealed moderate agreement between the single-item of fear avoidance and FAB-TBI, with regard to baseline, posttreatment, and change scores. With the exception of a few outliers, the majority of data points fell within the 95% limits of agreement. Terwee et al. [ 25 ] recommended that no more than 15% of participants should achieve the highest and lowest scores on a given scale. Having strong floor and ceiling effects can indicate limited content validity and reliability as the measure is not able to accurately distinguish between people who have varying degrees of symptom severity. In the present study, 22% of the sample scored either 1 (lowest possible score) or 10 (highest possible score) on the single-item measure at baseline, and 29% achieved these floor or ceiling scores posttreatment. The single-item avoidance scale was sensitive to change from pre- to post-treatment (noted the shifted distribution from Fig. 4a to Fig. 4b) and the magnitude of change correlated with the change on the FAB-TBI. However, the floor and ceiling effects suggest that the single-item avoidance scale may miss or underestimate important changes in people with very high or very low fear avoidance. The main appeal of single-item scales is their practicality and efficiency. The single-item measure of fear avoidance may be a useful screening and monitoring tool for patients with mTBI when constrained for time. Supplementing a core battery of questionnaires with the single-item measure of fear avoidance is more advantageous than not assessing fear avoidance behavior at all. The early assessment of fear avoidance behavior following mTBI can help clinicians identify and target maladaptive coping strategies sooner and improve outcomes (Silverberg et al., 2022). Additionally, a single-item measure is useful for repeated measurements, such as in the case of ecological momentary assessment. Having a brief measure can help monitor the progression of a patient’s fear avoidance behavior over the course of treatment. In the present study, the sample was predominantly White and female, only included treatment-seeking patients, and excluded older adults. Thus, the findings may not generalize to the broader population. As such, further validation of the single-item avoidance scale is warranted. Conclusion The single-item fear avoidance measure may be a useful screening and monitoring tool for patients with mTBI when constrained for time. However, it is not a substitute for the FAB-TBI questionnaire, which should be used to assess fear avoidance after mild TBI when greater precision is desirable. Abbreviations mTBI = mild traumatic brain injury FAB-TBI = Fear Avoidance Behavior after Traumatic Brain Injury TBI = traumatic brain injury PHQ-9 = Patient Health Questionnaire 9 GAD-7 = General Anxiety Questionnaire 7 WHODAS = World Health Organization Disability Assessment RPQ = Rivermead Postconcussion Symptoms Questionnaire IQR = Interquartile range LOC = Loss of consciousness PTA = post-traumatic amnesia Declarations Author contributions Shahrazad Amin: original draft, statistical analysis, and editing. Ana Mikolic: review and editing. Noah Silverberg: conceptualization, review and editing. Ethics approval and consent to participate All participants provided written consent prior to participating in the study. Study methods and procedures were approved by the Clinical Research Ethics Board at the University of British Columbia (#H18-02344). Consent for publication Not applicable. Competing interests The authors have no competing interests to declare. Availability of data and materials Datasets are not publicly available due to patient privacy. Funding This study was partially funded by the Vancouver General Hospital and University of British Columbia (UBC) Hospital Foundation. Ana Mikolic was funded by the UBC Institute of Mental Health (UBC IMH) Marshall Fellows Program. Acknowledgements We would like to thank participants for taking the time to participate in the study. Author information 1 Department of Psychology, University of British Columbia — Vancouver, British Columbia, Canada. 2 Rehabilitation Research Program at GF Strong Rehab Centre, Centre for Aging SMART, Vancouver, British Columbia, Canada. References Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, et al. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol. 2022;21:1004–60. Cancelliere C, Verville L, Stubbs JL, Yu H, Hincapié CA, Cassidy JD, et al. 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Supplementary Files Appendix.docx Cite Share Download PDF Status: Published Journal Publication published 28 Sep, 2024 Read the published version in BMC Neurology → Version 1 posted Editorial decision: Revision requested 24 Jun, 2024 Reviews received at journal 06 Jun, 2024 Reviewers agreed at journal 27 May, 2024 Reviews received at journal 28 Mar, 2024 Reviewers agreed at journal 11 Mar, 2024 Reviewers invited by journal 27 Feb, 2024 Editor assigned by journal 27 Feb, 2024 Submission checks completed at journal 26 Feb, 2024 First submitted to journal 21 Feb, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3977522","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":275454947,"identity":"938f33d1-5f94-4a2e-8c52-baa8f543e58d","order_by":0,"name":"Shahrazad Amin","email":"","orcid":"","institution":"University of British Columbia — Vancouver","correspondingAuthor":false,"prefix":"","firstName":"Shahrazad","middleName":"","lastName":"Amin","suffix":""},{"id":275454948,"identity":"506f7f9e-87bc-483b-950c-1916e774a7dd","order_by":1,"name":"Ana Mikolic","email":"","orcid":"","institution":"University of British Columbia — Vancouver","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"","lastName":"Mikolic","suffix":""},{"id":275454949,"identity":"fbf461b1-f87c-4dbe-975f-3380ee7d4ec8","order_by":2,"name":"Noah D. Silverberg","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+UlEQVRIiWNgGAWjYHACNiCWkIEyGOQYJIjUwgPTYkysFga4lsQGQlrM2ZufPWD4Y8FjcLz32YOPe2rTN9xufsDwowa3FsueY+YGjG0SPAZnjpsbznh2PHfDnWMGjD3HcGsxuJFgJsHYIMEjOSONTZrnwLHcDTdyGJghjsSlJf2bBMMfoJb5z9ik/xw4lm4A1vIPn5YcMwkGNgkefgk2NmmGAzUJYC2MbXi0nDlTJpEI9As/Txq7Yc+BA4YzgX452NuHR8vx9m0SH/7UybGxH2N78ONAnTzf7eaHD358w60FDBIQzMNg8gABDSigjhTFo2AUjIJRMEIAAHGdTm+eQCqrAAAAAElFTkSuQmCC","orcid":"","institution":"University of British Columbia — Vancouver","correspondingAuthor":true,"prefix":"","firstName":"Noah","middleName":"D.","lastName":"Silverberg","suffix":""}],"badges":[],"createdAt":"2024-02-22 04:18:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3977522/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3977522/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12883-024-03861-3","type":"published","date":"2024-09-28T15:56:54+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":51823437,"identity":"768d5dcb-b19f-4c00-a039-e3a83ebca640","added_by":"auto","created_at":"2024-02-29 16:28:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":37925,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e1a \u003c/strong\u003e\u003cem\u003eBland-Altman Plot Exploring Agreement Between Single-Item and FAB-TBI at Baseline\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1b \u003c/strong\u003e\u003cem\u003eBland-Altman Plot Exploring Agreement Between Single-Item and FAB-TBI Posttreatment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e Figures 1a and 1b represent the Bland-Altman plots of the total standardized scores of the single-item measure of fear avoidance and FAB-TBI at baseline and posttreatment, respectively.\u003c/p\u003e\n\u003cp\u003eStandardization involved subtracting the mean from the total score, and dividing by the standard deviation (sd), or [(value – mean)/sd]. The X axis represents the average of the single-item measure of fear avoidance and FAB-TBI, or [(single-item + FAB-TBI)/2]. The Y axis represents the difference between the single-item measure of fear avoidance and FAB-TBI, or single-item minus FAB-TBI. Positive Y axis values indicate that standardized scores in the single-item measure of fear avoidance are greater than standardized FAB-TBI scores. Negative values on the Y axis indicate that standardized FAB-TBI scores were greater than the standardized single-item scores. The dotted lines display the 95% limits of agreement, and the dashed line represents the mean difference.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1c \u003c/strong\u003e\u003cem\u003eBland-Altman Plot Exploring Agreement Between Change in Scores between Baseline and Posttreatment in the Single-Item and FAB-TBI\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e Figure 1c represents the change in total standardized scores of the single-item measure of fear avoidance and FAB-TBI between baseline and posttreatment. The change in scores was calculated by subtracting scores at baseline from the scores posttreatment [(score posttreatment) – (score at baseline)], for both the single-item measure and FAB-TBI. The X axis represents the change in the average score of both the single-item measure of fear avoidance and FAB-TBI, or [(change score of single-item + change score of FAB-TBI)/2]. The Y axis represents the difference between the change in scores between baseline and posttreatment in the single-item measure of fear avoidance and FAB-TBI, or [(change score of single-item - change score of FAB-TBI). Positive Y axis values indicate that standardized scores in the single-item measure of fear avoidance are greater than standardized FAB-TBI scores. Negative values on the Y axis indicate that standardized FAB-TBI scores were greater than the standardized single-item scores. The dotted lines display the 95% limits of agreement, and the dashed line represents the mean difference.\u003c/p\u003e","description":"","filename":"F1.png","url":"https://assets-eu.researchsquare.com/files/rs-3977522/v1/6579a2539d3da240c2e174a9.png"},{"id":65627158,"identity":"be79c6ca-cee7-4743-b1e1-8ae82ae30ed4","added_by":"auto","created_at":"2024-09-30 16:12:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":463521,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3977522/v1/475b4e2a-c47e-43ef-a5bb-571c849a659c.pdf"},{"id":51823439,"identity":"4072143c-94fb-42e5-a2fa-95443ac4215e","added_by":"auto","created_at":"2024-02-29 16:28:33","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":522175,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-3977522/v1/1c407a09186cddcf87723291.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Criterion Validity of a Single-Item Measure of Fear Avoidance Behavior Following Mild Traumatic Brain Injury","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEvery year, 50\u0026ndash;60\u0026nbsp;million people sustain a traumatic brain injury worldwide and 80\u0026ndash;90% of TBIs are classified as mild [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. At least 20% of adults with mild TBI experience persistent post-concussion symptoms, such as headaches, memory problems, and fatigue [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Maladaptive coping with post-concussion symptoms can hinder recovery from mild TBI. Perhaps the best studied maladaptive coping style after mild TBI to date is fear avoidance behavior. Fear avoidance refers to avoiding or escaping from activities and situations that the injured person expects might aggravate their symptoms or result in other harms (e.g., re-injury, social embarrassment, etc.). Prolonged fear avoidance is associated with worse post-concussion symptoms and disability [\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], heightened sensitivity to symptom provocation [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], and lower rates of return to work [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Targeting fear avoidance psychologically-informed rehabilitation may improve mild TBI outcomes [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMost prior studies have measured fear avoidance behavior after mild TBI with the 16-item Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This scale was adapted from existing measures of fear avoidance in the chronic pain literature. The FAB-TBI has high internal consistency and acceptable unidimensionality [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], and clinical reference values are available [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. With 16 items, the FAB-TBI is somewhat lengthy, which can be prohibitive for regular use in clinical settings and in research studies where fear avoidance may be relevant, but is not of primary interest.\u003c/p\u003e \u003cp\u003eAn ultra-brief fear avoidance scale would allow for more widespread measurement of this important construct. Single-item measures of psychological constructs can be reliable and valid [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The present study aimed to evaluate a single-item measure of fear avoidance. A single-item fear avoidance scale could be useful for screening, serial monitoring, and for ecological momentary assessment, which involve intensive repeated measurements [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAims\u003c/p\u003e \u003cp\u003eThis study aims to investigate the criterion validity of a brief, single-item measure of avoidance following mild TBI. We report the association and agreement between the single-item fear avoidance measure and the legacy FAB-TBI scale. We further examined associations between the single-item fear avoidance measure and clinical outcomes that are correlated with fear avoidance as measured by the FAB-TBI [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], including depression, anxiety, post-concussion symptoms, and disability.\u003c/p\u003e"},{"header":"Methods","content":" \u003cp\u003eStudy population\u003c/p\u003e \u003cp\u003eThis is a secondary analysis of a randomized controlled trial investigating the feasibility of two behavioral interventions following concussion [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The study was approved by the Clinical Research Ethics Board at the University of British Columbia (H18-02344). Detailed methods for the parent study are reported elsewhere [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe sample was comprised of N\u0026thinsp;=\u0026thinsp;90 adults (\u0026lt;\u0026thinsp;70 years old) who were recruited from two concussion clinics in British Columbia, Canada and sustained an mTBI between 1\u0026ndash;12 months prior. Eligible participants had persistent, moderate to severe post-concussion symptoms as measured by the Rivermead Postconcussion Symptom Questionnaire [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], and high avoidance and/or endurance behavior [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Participants completed questionnaires twice: once at clinic intake (M\u0026thinsp;=\u0026thinsp;18.2 weeks post injury) and again 12\u0026ndash;16 weeks later (M\u0026thinsp;=\u0026thinsp;32.2 weeks post injury, \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;82) following treatment. Treatments targeted two different coping styles: fear avoidance (graded exposure therapy) or endurance behavior (operant conditioning-based pacing and mindfulness training) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and were delivered via videoconference over the span of eight weeks. All participants had unrestricted access to usual care. Information about participant demographics and injury mechanism were collected at baseline. Ninety participants completed both the single-item fear avoidance measure and FAB-TBI at baseline/pre-treatment, and 82 of these participants also completed both measures post-treatment.\u003c/p\u003e \u003cp\u003eMeasures\u003c/p\u003e \u003cp\u003eSingle-Item Fear Avoidance Measure\u003c/p\u003e \u003cp\u003eParticipants were asked how strongly they agree with the following statement \u0026ldquo;\u003cem\u003eI avoid activities that might make my symptoms worse\u003c/em\u003e\u0026rdquo; over the past week, on a 10-point Likert scale from 1 (\u003cem\u003eStrongly disagree\u003c/em\u003e) to 10 (\u003cem\u003eStrongly agree\u003c/em\u003e).\u003c/p\u003e \u003cp\u003eFear Avoidance Behavior after Traumatic Brain Injury Questionnaire (FAB-TBI)\u003c/p\u003e \u003cp\u003eThe FAB-TBI is a validated 16 item self-report scale [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Items are assessed on a scale of 0 (\u003cem\u003eStrongly disagree\u003c/em\u003e) to 3 (\u003cem\u003eStrongly agree\u003c/em\u003e), where high scores indicate greater fear avoidance behavior. It includes items that reflect cogniphobia (e.g., \u0026ldquo;\u003cem\u003eI worry that when I have to think or concentrate too hard that I will bring on a headache\u003c/em\u003e\u0026rdquo;) and general activity avoidance (e.g., \u0026ldquo;\u003cem\u003eI have avoided my usual activities\u003c/em\u003e\u0026rdquo;). Raw scores are converted into Rasch scores to convert ordinal scores to a linear scale [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePatient Health Questionnaire 9 (PHQ-9)\u003c/p\u003e \u003cp\u003eThe PHQ-9 is a nine-item self-report measure of depression symptom severity [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Each of the items corresponds to one of the criteria that assesses depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), where scores are assessed from 0 (\u003cem\u003eNot at all\u003c/em\u003e) to 3 (\u003cem\u003eNearly every day\u003c/em\u003e). The total score is the sum of all the individual items. The PHQ-9 has demonstrated excellent internal reliability (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.89) and test-retest reliability and is a valid measure of depression severity [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGeneral Anxiety Questionnaire 7 (GAD-7)\u003c/p\u003e \u003cp\u003eThe GAD-7 is a seven-item self-report measure of generalized anxiety [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Items are assessed on a four-point rating scale ranging from 0 (\u003cem\u003eNot at all\u003c/em\u003e) to 4 (\u003cem\u003eNearly every day\u003c/em\u003e). The total score of the GAD-7 is the sum of the scores on the 7 items. The GAD-7 has good test-retest reliability, construct validity, and criterion validity, and excellent internal consistency (Cronbach α\u0026thinsp;=\u0026thinsp;.92).\u003c/p\u003e \u003cp\u003eWorld Health Organization Disability Assessment (WHODAS)\u003c/p\u003e \u003cp\u003eWorld Health Organization Disability Assessment Schedule 2.0 12-item interviewer version assesses functioning across six domains of the International Classification of Disability, Functioning, and Health [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]: cognition, mobility, self-care, interpersonal functioning, life activities, and participation. The WHODAS demonstrates high internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.86) and excellent test-retest reliability in a general population. The WHODAS has also been evaluated in a mild TBI sample, where it showed high internal consistency (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.92) and adequate construct and concurrent validity [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A Rasch transformation to WHODAS scores was applied to enhance psychometric properties in a mTBI sample, using ordinal to interval score conversions [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRivermead Postconcussion Symptoms Questionnaire (RPQ)\u003c/p\u003e \u003cp\u003eThe RPQ is a 16-item self-report scale that assesses symptom severity following mTBI [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Participants were asked to compare their symptoms in the past 24 hours to prior to their injury on a scale from 0 (\u003cem\u003eNot experienced at all\u003c/em\u003e) to 4 (\u003cem\u003eA severe problem\u003c/em\u003e). Some symptoms assessed by the RPQ include headaches, dizziness, nausea, sleep disturbances, fatigue, and concentration problems. The total score is the sum of all the individual items with 1 (\u0026ldquo;no more of a problem\u0026rdquo;) recoded as 0.\u003c/p\u003e \u003cp\u003eStatistical analyses\u003c/p\u003e \u003cp\u003eInformation about participant demographics and injury characteristics were described in terms of mean, standard deviation, and frequency. To assess the criterion validity of the single-item measure of fear avoidance, we examined its correlation and agreement with the 16-item FAB-TBI. Bland-Altman plots were used to explore the agreement between the single-item measure of fear avoidance and FAB-TBI at baseline, posttreatment, and the change in scores between baseline and posttreatment. Values of the single-item avoidance measure and FAB-TBI were standardized, by subtracting each participant\u0026rsquo;s score from the mean of the total sample, then dividing that value by the standard deviation of the sample. Each point in the scatterplot represents a participant, where the X-axis represents the average score of the single-item measure and FAB-TBI, and the Y-axis represents the difference in standardized scores between the two measures of fear avoidance. Change in scores was calculated by subtracting scores at baseline from the scores posttreatment [(score posttreatment) \u0026ndash; (score at baseline)], for both the single-item measure and FAB-TBI. Data points clustering close to the horizontal midpoint indicate high agreement, whereas greater dispersion signifies lower levels of agreement [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The limits of agreement were derived by calculating the mean difference between the measurements, and then establishing the 95% confidence interval around the mean difference by subtracting +/- 1.96 multiplied by the standard deviation of the difference. Scores above the 2.5th and below the 97.5th percentile fall within the limits of agreement [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe convergent validity of the single-item measure of fear avoidance was assessed using correlation with related measures, including post-concussion symptoms (RPQ) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], depression (PHQ-9) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], anxiety (GAD-7) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], and disability outcomes (WHODAS) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In addition, we calculated the correlation between change in single-item and FAB-TBI scores before and after treatment. Spearman\u0026rsquo;s rank correlation coefficient (\u003cem\u003eρ\u003c/em\u003e) was used due to the non-normal distribution of single-item avoidance scale scores (Appendix 1a, 1b) and monotonic relationship between single item and other measures. To facilitate comparisons, we report Spearman\u0026rsquo;s \u003cem\u003eρ\u003c/em\u003e for all other correlations. Statistical analyses were conducted using R version 1.4.1103 and SPSS version 27.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe current study included N = 90 participants at baseline and \u003cem\u003en\u0026nbsp;\u003c/em\u003e= 82 participants posttreatment. Of the eight participants that did not complete their assessment post-treatment, two participants (n = 2) withdrew from the study and six (n = 6) participants did not complete their outcome assessment following treatment. The majority of included participants were women (63.3%) and White (75.6%). The median age of the sample was 40.5 years (range = 20-65). See Table 1 for full demographic and injury characteristics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDescriptive statistics for the full sample are shown in Table 2. In terms of single-item avoidance scale scores at baseline/pre-treatment, the median score was 6 (Q1- Q3: 3-8). Posttreatment, the median score was 3 (Q1- Q3: 1.25-6). The total score of the single-item measure of fear avoidance showed minimal floor (7.8%, \u003cem\u003en\u003c/em\u003e = 7) and ceiling effects (14.4%, \u003cem\u003en\u003c/em\u003e = 13) at baseline. At follow up, a greater percentage demonstrated floor levels (23.3%, n = 21), however the ceiling effects were diminished (3.7%, \u003cem\u003en\u0026nbsp;\u003c/em\u003e= 3). Frequency distributions for single-item avoidance scale (Appendix 1a, 1b) and the FAB-TBI (Appendix 2a, 2b) are available in the supplementary materials. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFAB-TBI scores demonstrate a normal, unimodal distribution both at baseline (Appendix 2a) and following treatment (Appendix 2b). Scores for both FAB-TBI and the single-item measure of fear avoidance decreased on average following treatment, as expected, as treatments aimed to reduce fear avoidance behavior (Appendix 1, Appendix 2).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003e\u003cem\u003eParticipant demographic and clinical characteristics (N=90)\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.111111111111114%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.888888888888886%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.111111111111114%\" valign=\"top\"\u003e\n \u003cp\u003eAge, Mean (SD),\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.888888888888886%\" valign=\"top\"\u003e\n \u003cp\u003e41.59 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.111111111111114%\" valign=\"top\"\u003e\n \u003cp\u003eSex, n\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(% female)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.888888888888886%\" valign=\"top\"\u003e\n \u003cp\u003e57 (63.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.111111111111114%\" valign=\"top\"\u003e\n \u003cp\u003eEthnicity, n (%)\u003c/p\u003e\n \u003cp\u003eWhite\u003c/p\u003e\n \u003cp\u003eAsian\u003c/p\u003e\n \u003cp\u003eMiddle Eastern\u003c/p\u003e\n \u003cp\u003eAfrican\u003c/p\u003e\n \u003cp\u003eIndigenous\u003c/p\u003e\n \u003cp\u003eHispanic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.888888888888886%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e67 (75.6%)\u003c/p\u003e\n \u003cp\u003e15 (16.5%)\u003c/p\u003e\n \u003cp\u003e5 (5.5%)\u003c/p\u003e\n \u003cp\u003e1 (1.1%)\u003c/p\u003e\n \u003cp\u003e1 (1.1%)\u003c/p\u003e\n \u003cp\u003e1 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.111111111111114%\" valign=\"top\"\u003e\n \u003cp\u003eYears Education, M (SD)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.888888888888886%\" valign=\"top\"\u003e\n \u003cp\u003e15.46 (2.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.111111111111114%\" valign=\"top\"\u003e\n \u003cp\u003eMechanism of Injury, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003cp\u003eMoving head\u003c/p\u003e\n \u003cp\u003eWhiplash no contact\u003c/p\u003e\n \u003cp\u003eMoving object\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.888888888888886%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e63 (70.0%)\u003c/p\u003e\n \u003cp\u003e18 (20.0%)\u003c/p\u003e\n \u003cp\u003e9 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.111111111111114%\" valign=\"top\"\u003e\n \u003cp\u003eLOC, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eSuspected\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.888888888888886%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11 (12.2%)\u003c/p\u003e\n \u003cp\u003e10 (11.1%)\u003c/p\u003e\n \u003cp\u003e62 (68.9%)\u003c/p\u003e\n \u003cp\u003e5 (5.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.111111111111114%\" valign=\"top\"\u003e\n \u003cp\u003ePTA, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e\n \u003cp\u003eYes\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.888888888888886%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e43 (47.8%)\u003c/p\u003e\n \u003cp\u003e46 (51.1%)\u003c/p\u003e\n \u003cp\u003e1 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"56.111111111111114%\" valign=\"top\"\u003e\n \u003cp\u003eConfusion\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"43.888888888888886%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e84 (93.3%)\u003c/p\u003e\n \u003cp\u003e4 (4.4%)\u003c/p\u003e\n \u003cp\u003e1 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote\u003c/em\u003e. M = Mean, SD = Standard Deviation, LOC = Loss of consciousness; PTA = post-traumatic amnesia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003e\u003cem\u003eDescriptive statistics of psychological self-report measures\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.13804173354735%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eScale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.449438202247194%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"41.41252006420546%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePosttreatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.95088408644401%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.95088408644401%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMin - Max\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.95088408644401%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.147347740667975%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMin - Max\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.167202572347268%\" valign=\"top\"\u003e\n \u003cp\u003eSingle-item fear avoidance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" valign=\"top\"\u003e\n \u003cp\u003e5.8 (2.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1 - 10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" valign=\"top\"\u003e\n \u003cp\u003e3.9 (2.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.578778135048232%\" valign=\"top\"\u003e\n \u003cp\u003e1 - 10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.167202572347268%\" valign=\"top\"\u003e\n \u003cp\u003eFAB-TBI Rasch\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" valign=\"top\"\u003e\n \u003cp\u003e23.7 (7.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e6.05 - 48.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" valign=\"top\"\u003e\n \u003cp\u003e18.2 (6.89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.578778135048232%\" valign=\"top\"\u003e\n \u003cp\u003e0 - 34.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.167202572347268%\" valign=\"top\"\u003e\n \u003cp\u003eGAD-7\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" valign=\"top\"\u003e\n \u003cp\u003e9.2 (5.15)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0 - 21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" valign=\"top\"\u003e\n \u003cp\u003e5.8 (5.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.578778135048232%\" valign=\"top\"\u003e\n \u003cp\u003e0 - 21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.167202572347268%\" valign=\"top\"\u003e\n \u003cp\u003ePHQ-9\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" valign=\"top\"\u003e\n \u003cp\u003e12.4 (5.70)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e1 - 27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" valign=\"top\"\u003e\n \u003cp\u003e7.7 (5.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.578778135048232%\" valign=\"top\"\u003e\n \u003cp\u003e0 - 26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.167202572347268%\" valign=\"top\"\u003e\n \u003cp\u003eWHODAS Rasch\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" valign=\"top\"\u003e\n \u003cp\u003e19.8 (3.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e10.09 - 27.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" valign=\"top\"\u003e\n \u003cp\u003e14.3 (5.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.578778135048232%\" valign=\"top\"\u003e\n \u003cp\u003e0 - 26.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"18.167202572347268%\" valign=\"top\"\u003e\n \u003cp\u003eRPQ baseline\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" valign=\"top\"\u003e\n \u003cp\u003e33.9 (14.41)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e0 - 61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.418006430868168%\" valign=\"top\"\u003e\n \u003cp\u003e22.9 (14.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.578778135048232%\" valign=\"top\"\u003e\n \u003cp\u003e0 - 54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eNote.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFAB-TBI = Fear Avoidance Behavior after Traumatic Brain Injury Questionnaire\u003c/p\u003e\n\u003cp\u003eGAD-7 = General Anxiety Questionnaire 7\u003c/p\u003e\n\u003cp\u003ePHQ-9 = Patient Health Questionnaire\u003c/p\u003e\n\u003cp\u003eWHODAS = World Health Organization Disability Assessment\u003c/p\u003e\n\u003cp\u003eRPQ = Rivermead Postconcussion Symptoms Questionnaire\u003c/p\u003e\n\u003cp\u003eSD = Standard Deviation\u003c/p\u003e\n\u003cp\u003eAt baseline, a moderately strong positive correlation was observed between the single-item fear avoidance measure and FAB-TBI (\u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e=\u003cem\u003e\u0026nbsp;\u003c/em\u003e.67, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001) The single-item fear avoidance measure correlated moderately with anxiety (GAD-7; \u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e= .34, p \u0026lt; .001), depression (PHQ-9; \u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e= .43, p \u0026lt; .001), post-concussion symptoms (RPQ; \u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;=\u0026nbsp;\u003c/em\u003e.50, p \u0026lt; .001), and disability (WHODAS; \u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e=\u003cem\u003e\u0026nbsp;\u003c/em\u003e.43,\u0026nbsp;p \u0026lt; .001). The FAB-TBI was more strongly correlated with these measures: anxiety (\u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e= .53; \u003cem\u003ep\u003c/em\u003e \u0026lt; .001), depression (\u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e= .71; \u003cem\u003ep\u003c/em\u003e \u0026lt; .001), post-concussion symptoms (\u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;=\u0026nbsp;\u003c/em\u003e.73; \u003cem\u003ep\u003c/em\u003e \u0026lt; .001) and disability (\u003cem\u003e\u0026rho;\u003c/em\u003e = .66; \u003cem\u003ep\u003c/em\u003e \u0026lt; .001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePosttreatment, there was a moderate correlation between the single-item fear avoidance measure and FAB-TBI (\u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;=\u0026nbsp;\u003c/em\u003e.63, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001). Following treatment, the single-item fear avoidance measure correlated moderately with anxiety (GAD-7; \u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e= .38, p \u0026lt; .001), depression (PHQ-9; \u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e= .47, p \u0026lt; .001), post-concussion symptoms (RPQ; \u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e= .53, p \u0026lt; .001), and disability (WHODAS; \u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e= .53,\u0026nbsp;p \u0026lt; .001). Again, the FAB-TBI was more strongly correlated with these measures: anxiety (\u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e= .59; \u003cem\u003ep\u003c/em\u003e \u0026lt; .001), depression (\u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e= .64; \u003cem\u003ep\u003c/em\u003e \u0026lt; .001), post-concussion symptoms (\u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e= .72; \u003cem\u003ep\u003c/em\u003e \u0026lt; .001) and disability (\u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e= .71; \u003cem\u003ep\u003c/em\u003e \u0026lt; .001). The correlation between the change scores from baseline to posttreatment for the single-item fear avoidance measure and FAB-TBI was moderate (\u003cem\u003e\u0026rho;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e= .45, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInspection of the Bland-Altman plots suggested moderate agreement between the single-item fear avoidance measure and FAB-TBI both before (Figure 1) and after (Figure 2) treatment. At both baseline and posttreatment, most values were inside the limits of agreement. A mean standardized difference of -0.02 (-1.66, 1.62) was observed between the single-item fear avoidance measure and FAB-TBI at baseline, indicating that the single-item measure did not systematically under- or overestimate FAB-TBI scores. The mean standardized difference following treatment was .78 (-1.04, 2.62), indicating that participants tended to score slightly lower on the single-item fear avoidance measure as compared to FAB-TBI, however this difference is negligible. Posttreatment, participants scored higher on the single-item measure as compared to FAB-TBI. There was a negligible difference between the standardized change scores [.01 (-2.15, 2.16)], indicating that there is high agreement between in the change in standardized scores from baseline to posttreatment. In addition, the relatively symmetrical distribution of difference scores further supports the agreement of the change scores.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1a\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBland-Altman Plot Exploring Agreement Between Single-Item and FAB-TBI at Baseline\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1b\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBland-Altman Plot Exploring Agreement Between Single-Item and FAB-TBI Posttreatment\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e Figures 1a and 1b represent the Bland-Altman plots of the total standardized scores of the single-item measure of fear avoidance and FAB-TBI at baseline and posttreatment, respectively.\u003c/p\u003e\n\u003cp\u003eStandardization involved subtracting the mean from the total score, and dividing by the standard deviation (sd), or [(value \u0026ndash; mean)/sd]. The X axis represents the average of the single-item measure of fear avoidance and FAB-TBI, or [(single-item + FAB-TBI)/2]. The Y axis represents the difference between the single-item measure of fear avoidance and FAB-TBI, or single-item minus FAB-TBI. Positive Y axis values indicate that standardized scores in the single-item measure of fear avoidance are greater than standardized FAB-TBI scores. Negative values on the Y axis indicate that standardized FAB-TBI scores were greater than the standardized single-item scores. The dotted lines display the 95% limits of agreement, and the dashed line represents the mean difference.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1c\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBland-Altman Plot Exploring Agreement Between Change in Scores between Baseline and Posttreatment in the Single-Item and FAB-TBI\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eNote.\u003c/em\u003e Figure 1c represents the change in total standardized scores of the single-item measure of fear avoidance and FAB-TBI between baseline and posttreatment. The change in scores was calculated by subtracting scores at baseline from the scores posttreatment [(score posttreatment) \u0026ndash; (score at baseline)], for both the single-item measure and FAB-TBI. The X axis represents the change in the average score of both the single-item measure of fear avoidance and FAB-TBI, or [(change score of single-item + change score of FAB-TBI)/2]. The Y axis represents the difference between the change in scores between baseline and posttreatment in the single-item measure of fear avoidance and FAB-TBI, or [(change score of single-item - change score of FAB-TBI). Positive Y axis values indicate that standardized scores in the single-item measure of fear avoidance are greater than standardized FAB-TBI scores. Negative values on the Y axis indicate that standardized FAB-TBI scores were greater than the standardized single-item scores. The dotted lines display the 95% limits of agreement, and the dashed line represents the mean difference.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study examined the criterion validity of a single-item measure of fear avoidance after mild TBI. We observed a moderately strong positive correlation between the single-item fear avoidance measure and FAB-TBI at baseline, indicating that these two scales may measure the same construct, or at least that there is overlap in what they measure. The strength of these correlations (\u003cem\u003eρ\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.67 at baseline and \u003cem\u003eρ\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.63 post treatment) approached the benchmark of \u0026gt;\u0026thinsp;.70 suggested by previous studies as indicator of criterion validity of a single-item scale [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Additionally, the correlation between the change in scores from baseline to posttreatment between the single-item and FAB-TBI was moderate (\u003cem\u003eρ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.45, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003cp\u003eThe single-item of fear avoidance demonstrated adequate convergent validity by correlating with measures of anxiety, depression, post-concussion symptoms, and disability. However, correlations between the single-item measure of fear avoidance and related constructs were somewhat weaker than the correlations between FAB-TBI and related constructs. The stronger associations may be explained by the fact that FAB-TBI is a multi-item measure of fear avoidance, and is better able to capture a broader range of fear avoidance behavior.\u003c/p\u003e \u003cp\u003eThe single-item fear avoidance measure did not systematically under- or over-estimate FAB-TBI scores. The Bland-Altman analyses revealed moderate agreement between the single-item of fear avoidance and FAB-TBI, with regard to baseline, posttreatment, and change scores. With the exception of a few outliers, the majority of data points fell within the 95% limits of agreement.\u003c/p\u003e \u003cp\u003eTerwee et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] recommended that no more than 15% of participants should achieve the highest and lowest scores on a given scale. Having strong floor and ceiling effects can indicate limited content validity and reliability as the measure is not able to accurately distinguish between people who have varying degrees of symptom severity. In the present study, 22% of the sample scored either 1 (lowest possible score) or 10 (highest possible score) on the single-item measure at baseline, and 29% achieved these floor or ceiling scores posttreatment. The single-item avoidance scale was sensitive to change from pre- to post-treatment (noted the shifted distribution from Fig.\u0026nbsp;4a to Fig.\u0026nbsp;4b) and the magnitude of change correlated with the change on the FAB-TBI. However, the floor and ceiling effects suggest that the single-item avoidance scale may miss or underestimate important changes in people with very high or very low fear avoidance.\u003c/p\u003e \u003cp\u003eThe main appeal of single-item scales is their practicality and efficiency. The single-item measure of fear avoidance may be a useful screening and monitoring tool for patients with mTBI when constrained for time. Supplementing a core battery of questionnaires with the single-item measure of fear avoidance is more advantageous than not assessing fear avoidance behavior at all. The early assessment of fear avoidance behavior following mTBI can help clinicians identify and target maladaptive coping strategies sooner and improve outcomes (Silverberg et al., 2022). Additionally, a single-item measure is useful for repeated measurements, such as in the case of ecological momentary assessment. Having a brief measure can help monitor the progression of a patient\u0026rsquo;s fear avoidance behavior over the course of treatment.\u003c/p\u003e \u003cp\u003eIn the present study, the sample was predominantly White and female, only included treatment-seeking patients, and excluded older adults. Thus, the findings may not generalize to the broader population. As such, further validation of the single-item avoidance scale is warranted.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe single-item fear avoidance measure may be a useful screening and monitoring tool for patients with mTBI when constrained for time. However, it is not a substitute for the FAB-TBI questionnaire, which should be used to assess fear avoidance after mild TBI when greater precision is desirable.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003emTBI = mild traumatic brain injury\u003c/p\u003e\n\u003cp\u003eFAB-TBI =\u0026nbsp;Fear Avoidance Behavior after Traumatic Brain Injury\u003c/p\u003e\n\u003cp\u003eTBI = traumatic brain injury\u003c/p\u003e\n\u003cp\u003ePHQ-9 = Patient Health Questionnaire 9\u003c/p\u003e\n\u003cp\u003eGAD-7 = General Anxiety Questionnaire 7\u003c/p\u003e\n\u003cp\u003eWHODAS = World Health Organization Disability Assessment\u003c/p\u003e\n\u003cp\u003eRPQ = Rivermead Postconcussion Symptoms Questionnaire\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIQR = Interquartile range\u003c/p\u003e\n\u003cp\u003eLOC = Loss of consciousness\u003c/p\u003e\n\u003cp\u003ePTA = post-traumatic amnesia\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eShahrazad Amin: original draft, statistical analysis, and editing. Ana Mikolic: review and editing. Noah Silverberg: conceptualization, review and editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided written consent prior to participating in the study. Study methods and procedures were approved by the Clinical Research Ethics Board at the University of British Columbia (#H18-02344).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDatasets are not publicly available due to patient privacy.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was partially funded by the Vancouver General Hospital and University of British Columbia (UBC) Hospital Foundation. Ana Mikolic was funded by the UBC Institute of Mental Health (UBC IMH) Marshall Fellows Program.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank participants for taking the time to participate in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u0026nbsp;\u003c/sup\u003eDepartment of Psychology, University of British Columbia \u0026mdash; Vancouver, British\u003c/p\u003e\n\u003cp\u003eColumbia, Canada.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u0026nbsp;\u003c/sup\u003eRehabilitation Research Program at GF Strong Rehab Centre, Centre for Aging SMART, Vancouver, British Columbia, Canada.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMaas AIR, Menon DK, Manley GT, Abrams M, \u0026Aring;kerlund C, Andelic N, et al. 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Arch Intern Med. 2006;166:1092.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026Uuml;st\u0026uuml;n TB, Chatterji S, Kostanjsek N, Rehm J, Kennedy C, Epping-Jordan J, et al. Developing the World Health Organization Disability Assessment Schedule 2.0. Bull World Health Organ. 2010;88:815\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSnell DL, Siegert RJ, Silverberg ND. Rasch analysis of the World Health Organization Disability Assessment Schedule 2.0 in a mild traumatic brain injury sample. Brain Injury. 2020;34:610\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986;327:307\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res. 1999;8:135\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim H-J, Abraham I. Psychometric comparison of single-item, short, and comprehensive depression screening measures in Korean young adults. Int J Nurs Stud. 2016;56:71\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim H-J, Abraham I. Measurement of fatigue: Comparison of the reliability and validity of single-item and short measures to a comprehensive measure. Int J Nurs Stud. 2017;65:35\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTerwee CB, Bot SDM, De Boer MR, Van Der Windt DAWM, Knol DL, Dekker J, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60:34\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"fear avoidance, mTBI, outcome measures, psychometrics","lastPublishedDoi":"10.21203/rs.3.rs-3977522/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3977522/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMaladaptive coping such as fear avoidance behavior can prolong recovery from mild traumatic brain injury (mTBI). Routine assessment of fear avoidance may improve management of mTBI. This study aimed to validate a single-item measure of fear avoidance to make its assessment more pragmatic. The present study is a secondary analysis of a clinical trial that involved adults with persistent post-concussion symptoms (N\u0026thinsp;=\u0026thinsp;90, 63% female). Participants completed the single-item fear avoidance rating, a validated legacy measure of fear avoidance (Fear Avoidance Behavior after Traumatic Brain Injury; FAB-TBI), and measures of anxiety (General Anxiety Disorder-7), depression (Patient Health Questionnaire-9), post-concussion symptoms (Rivermead Postconcussion Symptoms Questionnaire), and disability (World Health Organization Disability Assessment Schedule 12.0). Questionnaires were completed twice, at baseline (mean 18.1 weeks post injury) and again 12\u0026ndash;16 weeks later following study-delivered rehabilitation in addition to usual care. We analyzed the associations (Spearman\u0026rsquo;s correlations) and agreement (Bland-Altman plots) between the single-item and FAB-TBI at baseline, posttreatment, and the change in scores between baseline and posttreatment. In addition, we examined correlations between the single-item avoidance scale and related constructs, including anxiety, depression, post-concussion symptoms, and disability. The single-item fear avoidance measure correlated strongly with the FAB-TBI both at baseline and following treatment (\u003cem\u003eρ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.63 \u0026minus;\u0026thinsp;.67, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). The correlation between the change in these scores from baseline to posttreatment was moderate (\u003cem\u003eρ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.45, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Before and after treatment, the single-item fear avoidance measure correlated moderately with anxiety (\u003cem\u003eρ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.34), depression (\u003cem\u003eρ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.43), post-concussion symptoms (\u003cem\u003eρ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.50), and disability (\u003cem\u003eρ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.43). The FAB-TBI was more strongly correlated with these measures (\u003cem\u003eρ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.53 \u0026minus;\u0026thinsp;.73). In summary, the present study supports the criterion validity of the single-item fear avoidance measure. This measure may be a useful screening and monitoring tool for patients with mTBI but is not a substitute for the FAB-TBI questionnaire.\u003c/p\u003e","manuscriptTitle":"Criterion Validity of a Single-Item Measure of Fear Avoidance Behavior Following Mild Traumatic Brain Injury","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-29 16:28:28","doi":"10.21203/rs.3.rs-3977522/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-24T12:01:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-06T07:56:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"84925825662933640471043094151332216102","date":"2024-05-27T05:30:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-03-28T18:27:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"4f69fc25-c585-427a-b0a0-cdcc739547e2","date":"2024-03-11T14:21:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-27T18:22:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-27T16:06:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-27T04:23:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2024-02-22T04:14:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6fd32311-7307-494c-9155-0d8d7f30e15f","owner":[],"postedDate":"February 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-09-30T16:01:13+00:00","versionOfRecord":{"articleIdentity":"rs-3977522","link":"https://doi.org/10.1186/s12883-024-03861-3","journal":{"identity":"bmc-neurology","isVorOnly":false,"title":"BMC Neurology"},"publishedOn":"2024-09-28 15:56:54","publishedOnDateReadable":"September 28th, 2024"},"versionCreatedAt":"2024-02-29 16:28:28","video":"","vorDoi":"10.1186/s12883-024-03861-3","vorDoiUrl":"https://doi.org/10.1186/s12883-024-03861-3","workflowStages":[]},"version":"v1","identity":"rs-3977522","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3977522","identity":"rs-3977522","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}