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Licensed Unlicensed Requires Authentication Published by De Gruyter September 7, 2020

Psychosocial subgroups in high-performance athletes with low back pain: eustress-endurance is most frequent, distress-endurance most problematic!

Christina Titze, Daniela Fett, Katharina Trompeter, Petra Platen, Hannah Gajsar and Monika I. Hasenbring



In non-athletes, fear-avoidance and endurance-related pain responses appear to influence the development and maintenance of low back pain (LBP). The avoidance-endurance model (AEM) postulates three dysfunctional pain response patterns that are associated with poorer pain outcomes. Whether comparable relationships are present in athletes is currently unclear. This cross-sectional case-control study explored frequencies and behavioral validity of the AEM-based patterns in athletes with and without LBP, as well as their outcome-based validity in athletes with LBP.


Based on the Avoidance-Endurance Fast-Screen, 438 (57.1% female) young adult high-performance athletes with and 335 (45.4% female) without LBP were categorized as showing a “distress-endurance” (DER), “eustress-endurance” (EER), “fear-avoidance” (FAR) or “adaptive” (AR) pattern.


Of the athletes with LBP, 9.8% were categorized as FAR, 20.1% as DER, 47.0% as EER, and 23.1% as AR; of the athletes without LBP, 10.4% were categorized as FAR, 14.3% as DER, 47.2% as EER, and 28.1% as AR. DER and EER reported more pronounced endurance- and less pronounced avoidance-related pain responses than FAR, and vice versa. DER further reported the highest training frequency. In athletes with LBP, all dysfunctional groups reported higher LBP intensity, with FAR and DER displaying higher disability scores than AR.


The results indicate that also in athletes, patterns of endurance- and fear-avoidance-related pain responses appear dysfunctional with respect to LBP. While EER occurred most often, DER seems most problematic.


Endurance-related pain responses that might be necessary during painful exercise should therefore be inspected carefully when shown in response to clinical pain.

Corresponding author: Christina Titze, Department of Medical Psychology and Medical Sociology, Ruhr-University of Bochum, Universitätsstr. 150, 44801 Bochum, Germany, Phone: +49 234 32 25438, Fax: +49 234 32 14203, E-mail:

  1. Research funding: This article was conducted within the MiSpEx (National Research Network for Medicine in Spine Exercise) research consortium. The authors are thankful to the German Olympic Sports Confederation (DOSB) for their help in the collection of data. This work was financially supported by the Federal Institute of Sports Science (BISp), Germany (ZMVI1-080102A/11-18).

  2. Competing interests: Authors state no conflict of interest.

  3. Informed consent: Informed consent has been obtained from all individuals included in this study.

  4. Ethical approval: The research related to human use complies with all the relevant national regulations, institutional policies and was performed in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.


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Received: 2020-04-10
Accepted: 2020-07-25
Published Online: 2020-09-07
Published in Print: 2021-01-27

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