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

The authors created their own clinical screening rules because no existing tool for this purpose was available, so the choices about what counts as clinically usable may not be standard. The appraisal of measurement quality used a checklist that the authors say is not validated for this kind of analysis. The two recommended tools were validated only for chronic low back pain, so their scores should not be treated as established for other musculoskeletal conditions. This is a review of assessment methods, not a trial of treatment, so it does not show that acting on the observed behaviors improves pain or function. The Behavioral Avoidance Test-Back Pain can overestimate avoidance if a patient stops a sequence early or if stiffness limits movement, and its first bending task may reflect physical limitation rather than fear. The Pain Behaviour Scale rates communicative behaviors, which may not always match pain severity or disability, and observers may give them too much weight. Endurance behaviors are less observable and may be missed by these tools; the authors suggest a questionnaire for suspected endurance patterns.

Do not use the Pain Behaviour Scale or BAT-Back as a general test for all musculoskeletal pain. The review says both are validated only for chronic low back pain, and the behavior list is for screening, not objective measurement.