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. Author manuscript; available in PMC: 2023 Jul 1.
Published in final edited form as: Behav Med. 2020 Jul 23;48(3):181–189. doi: 10.1080/08964289.2020.1796572

Fatigue Severity and Fatigue Sensitivity: Relations to Anxiety, Depression, Pain Catastrophizing, Pain Interference, and Pain Severity among Adults with Severe Fatigue and Chronic Low Back Pain

Kara Manning 1, Brooke Y Kauffman 1, Andrew H Rogers 1, Lorra Garey 1, Michael J Zvolensky 1,2,3
PMCID: PMC7854766  NIHMSID: NIHMS1615700  PMID: 32703094

Abstract

Chronic low back pain is the second leading cause of disability in the United States, and it is often associated with severe fatigue. However, little is known about individual differences that may be related to poorer mental health and pain among individuals with severe fatigue and chronic low back pain. The aim of the current investigation was to explore the role of fatigue severity and fatigue sensitivity in terms of anxiety and depressive symptoms, pain catastrophizing, pain interference, and pain severity among 783 adults with severe fatigue and chronic low back pain (76.1% female, Mage - 43.29 years, SD = 11.64). Results suggest that fatigue severity and fatigue sensitivity were statistically significant predictors for anxiety (β=0.17, 95% CI [0.10, 0.25], p<.001; β=0.40, 95% CI [0.33, 0.48], p<.001), depression (β=0.21, 95% CI [0.13, 0.28], p<.001; β=0.40, 95% CI [0.33, 0.47], p<.001), pain interference (β=0.15, 95% CI [0.06, 0.23], p=.001; β=0.25, 95% CI [0.17, 0.33], p<.001), and pain catastrophizing (β=0.12, 95% CI [0.0.04, 0.20], p=.003; β=0.49, 95% CI [0.42, 0.56], p<.001), respectively. However, only fatigue sensitivity significantly predicted pain severity (β=0.31, 95% CI [0.23, 0.38], p<.001). Overall, the current study provides initial support for the role of fatigue severity and fatigue sensitivity in the presence of mental and physical health complaints among individuals with severe fatigue and chronic low back pain.

Keywords: Fatigue, Chronic pain, Mental health, Health disparities

Introduction

Low back pain is highly prevalent in the United States (U.S.) with approximately 80% of adults experiencing low back pain at least once in their lifetime.1,2 Notably, acute lower back pain transitions into a chronic condition (i.e., lasting 3 months or more) for between 5% and 10% of patients with back pain.1 Chronic low back pain is the second leading cause of disability in the U.S., costing an average of $100 billion annually, and leads to increased health care utilization, higher treatment costs, and decreased productivity.1 Additionally, chronic low back pain is often associated with other physical health complaints, including fatigue, defined as an overwhelming sense of tiredness, exhaustion, or lack of energy, with more severe and chronic fatigue leading to greater functional impairment.3–8

Research suggests that individuals with chronic low back pain report experiencing more severe fatigue than healthy controls,5–8 even after controlling for potential explanatory variables, including sleep disturbance.6 Further, research on the co-occurrence of chronic low back pain and fatigue has found that severe fatigue is related to more severe pain.8 Although the exact nature of the fatigue-pain relation has yet to be established, it has been hypothesized that severe fatigue may deplete the resources necessary for an individual to effectively cope with or suppress pain, thereby intensifying the overall pain experience.9,10

Although past work has established fatigue severity as a clinically significant factor for adverse consequences (e.g., more severe pain, poorer mental health outcomes, etc.) among persons with chronic low back pain,5,8 there has been comparatively less focus on the relative explanatory value of this construct, in addition to other psychologically-based individual difference factors linked to fatigue states. One construct related to fatigue that has received recent attention for its role in psychological-related problems is fatigue sensitivity.11 Fatigue sensitivity denotes an individual difference in beliefs or expectations that the experience of fatigue related symptoms may lead to negative social, physical, or cognitive consequences.11 For example, an individual with elevated fatigue sensitivity may fear that fatigue-related symptoms (e.g., yawning) may lead to negative judgment from others.11 Fatigue sensitivity is theoretically and empirically distinct from the severity of fatigue symptoms.11 Past work has found that greater fatigue sensitivity is associated with greater negative mood symptoms, including depression, anxiety, and social anxiety.11 Unfortunately, to date, research on fatigue sensitivity is quite limited. There is a need to expand upon such work to bolster the clinical utility of this construct among health disparity populations.

Fatigue sensitivity may amplify emotional reactions to fatigue symptoms.11,12 Thus, fatigue sensitivity may be especially relevant to better understanding adverse mental health and pain-related problems among persons with chronic low back pain and severe fatigue. For example, theoretically, among individuals with chronic low back pain and severe fatigue, fatigue sensitivity may exacerbate condition specific fears (e.g., depression, irritability, etc.) and may generate an increased awareness of fatigue related symptoms. As such, individuals with elevated fatigue sensitivity may engage in behavioral withdrawal to avoid fatigue provoking stimuli. Such behavioral withdrawal and experience may contribute to poorer mental health functioning, such as increasing anxiety and depressed affect. Further, behavioral changes, such as avoiding physical activity, may lead to a sedentary lifestyle13 which has the potential to exacerbate pain related symptoms and pain-related cognition (i.e., catastrophizing).14,15

Although past work on fatigue severity and fatigue sensitivity is promising, a key gap in the existing literature pertains to whether these constructs both influence risk for more severe anxiety and depression as well as pain severity among persons with chronic low back pain and clinically significant fatigue when considered concurrently. Specifically, the relative effects of fatigue severity and fatigue sensitivity have not been directly explored in general or among persons with chronic low back pain and severe fatigue. Because both fatigue severity and fatigue sensitivity invoke distinct mechanisms designed to account for increased affective and pain-related burden,9–11 it is important to determine the extent of unique explanatory validity relative to one another in the same model. Further, it is important to examine fatigue sensitivity among those with severe fatigue as that is the population that is most pertinent to this construct, and it is important to understand how such relations will function among those with co-occurring health concerns. Answering such questions may enhance our understanding of important individual difference influences on mental health and pain experience among adults with chronic pain, suffering from fatigue symptoms and direct novel strategies for treatment development for this underserved group. This work would be especially useful if it demonstrates the incremental validity of these two constructs relative to other well-established factors linked to poorer mental health among this group, such as perceived health and age.16–19

The purpose of the current study therefore was to explore the role of fatigue severity and fatigue sensitivity with anxiety and depressive symptoms, pain catastrophizing, pain interference, and pain severity among adults with severe fatigue and chronic low back pain. It was hypothesized that fatigue severity and fatigue sensitivity would both be significant predictors of greater anxiety, depressive symptoms, pain catastrophizing, pain interference, and pain severity; however, as this is the first study to observe the effects of both fatigue variables in the same model, no predictions were made regarding the specific contributions of each independent variable. The fatigue severity and sensitivity effects were expected to be evident after adjusting for the variance accounted for by age, sex, and perceived health.16–19

Methods

Participants

Participants for the current study included 783 adults (76.1% female, Mage = 43.29 years, SD = 11.64) with self-reported clinical fatigue ≥ 5 as measured by the Fatigue Severity Scale;20 and current chronic low back pain. Participants were eligible to participate in the current study if they: (1) were between the ages of 18 and 64, (2) reported mild to severe chronic low back pain, and (3) self-reported severe fatigue defined as a fatigue score of ≥ 5;20 Exclusion criteria for the current study included: (1) non-fluency in English and (2) inability to provide informed, voluntary, written consent.

Most of the sample self-identified as White (83.3%). The remainder of the sample identified as follows: 9.1% African American/Black, 1.8% Asian/Pacific Islander, 0.8% Native American/American Indian, 2.8% multiracial, 1.9% other, and 0.4% preferred to not respond. Eleven percent of the sample self-identified as Latinx. The mean levels of fatigue severity and pain severity reported in the current sample were 5.98 and 5.90, respectively.

Measures

Demographic Questionnaire.

A Demographic Questionnaire was employed to obtain demographic information from the sample, including age, sex, race, and ethnicity. The variables age and sex were also utilized as covariates in the current study.

12-item Short Form Health Survey.

Perceived health was measured by a single item (i.e. “In general, how would you say your health is?”) taken from the 12-item Short Form Health Survey.21 This item was rated on a 5-point Likert-type scale ranging from 1 (excellent) to 5 (poor). Item responses were transformed into a scale from 0 to 100 with higher scores indicative of greater perceived health. This item was utilized as a covariate in the current study.

Fatigue Severity Scale.

Fatigue severity was measured with the 9-item Fatigue Severity Scale (FSS).20 Participants were asked to rate on a 7-point Likert-type scale the degree to which they experience impairment related to fatigue on a scale from 1 (strongly disagree) to 7 (strongly agree). Items were then averaged to create a total score. Past working utilizing the Fatigue Severity Scale among individuals with severe fatigue due to chronic health conditions established that a score of 5 or greater is at least 2 SD higher than fatigue scores of healthy controls.22 Thus, this cutoff score has been used consistently in past work to differentiate severe fatigue from non-severe fatigue.22,23 The FSS total score was utilized as a predictor in the current study, and it demonstrated good internal consistency (α = .73), consistent with past work.20

Fatigue Sensitivity Questionnaire.

The Fatigue Sensitivity Questionnaire (FSQ)11 is a 10-item self-report measure that assesses the tendency for individuals to interpret fatigue-related symptoms and sensations as having harmful physical, social, and/or cognitive consequences (e.g., “When I yawn in the presence of others, I fear what people might think of me.”) Each item is assessed on a 4-point Likert scale ranging from 0 (Very Little) to 3 (Much/Very Much). The total score was created by summing all items and was used as a predictor variable in the current study and demonstrated excellent internal consistency (α = .92).

Overall Depression Severity and Impairment Scale.

The Overall Depression Severity and Impairment Scale (ODSIS)24 is a 5-item measure that assesses depression symptoms over the past week. Items are rated on a 5-point Likert-type scale ranging from 0 to 4. The total score demonstrated excellent internal consistency (α = .95) and was utilized as a criterion variable in the current study.

Overall Anxiety Severity and Impairment Scale.

The Overall Anxiety Severity and Impairment Scale (OASIS)25 is a 5-item measure that assesses anxiety symptoms over the past week. Items are rated on a 5-point Likert-type scale ranging from 0 to 4. The total score demonstrated excellent internal consistency (α = .93) and was utilized as a criterion variable in the current study.

Brief Pain Inventory.

The Brief Pain Inventory (BPI)26 is an 9-item self-report measure that asks respondents to answer questions regarding their pain experience. The BPI has 2 subscales: (1) pain severity and (2) pain interference. Pain severity consists of 4-items in which participants are asked to rate their pain over the past 24 hours at ‘its worst’, ‘its least’, ‘on average’, and ‘right now’ on a scale from 0 (no pain) to 10 (pain as bad as you can imagine). Pain Interference is measured by asking respondents to report how pain has interfered with certain activities (7 activities listed; e.g., “sleep”) measured from 0 (does not interfere) to 10 (completely interferes). The pain severity (α = .91) and pain interference (α = .80) subscales were utilized as criterion variables in the current study.

Pain Catastrophizing Scale-Daily Version.

The Pain Catastrophizing Scale (PCS-DV)27 is a 3-item measure that assess the degree to which individuals misinterpret pain related symptoms. Specifically, the scale assesses for rumination, magnification, and perceived level of helplessness over the past 24 hours due to pain. Items are rated on a 5-point Likert-type scale ranging from 1 (not at all) to 5 (all of the time). In the current study, the PCS-DV was entered as a criterion variable. It demonstrated excellent internal consistency (α = 0.90).

Procedure

As in past work,28 participants for the current study were recruited through a reliable and valid online survey management system (Qualtrics).29 Individuals with a Qualtrics Panels account who endorsed mild to severe chronic low back pain were sent a survey advertisement to participate in the current study. Participants were asked 1) if they experience pain, 2) how severe is this pain (none, very mild, mild, moderate, severe), and 3) how long they have been experiencing the pain. Individuals were included in the study if they endorsed experiencing at least mild pain for the past three months. These inclusion criteria were specified to recruit a sample that reflected a clinical chronic pain population that might seek treatment. Those that were determined to meet the eligibility criteria were then redirected to complete the online anonymous Qualtrics survey. Participants who completed the survey were compensated by preference to receive various forms of compensations (e.g., gift cards, reward miles, reward points, etc.). It is important to note that Qualtrics automatically incorporates a quality assurance check, (measured as one-half the median soft launch time), which automatically terminates those who do not respond thoughtfully. The study protocol was approved by the Institutional Review Board where the study took place.

Analytic Strategy

First, participants that completed the survey in under half of the median response time across the entire sample were excluded to exclude any careless responders (n = 67). Then, sample descriptive statistics and bivariate correlations were examined among study variables using SPSS version 25.0. Remaining analyses were conducted using MPlus version 8.0.30 First, a measurement model with seven latent variables (fatigue severity, fatigue sensitivity, depression symptoms, anxiety, pain severity, pain interference, and pain catastrophizing) was evaluated using confirmatory factor analysis (CFA). Next, structural equation modeling (SEM) was used to simultaneously examine the effects of fatigue severity and fatigue sensitivity on the five outcome variables: depression symptoms, anxiety, pain severity, pain interference, and pain catastrophizing, controlling for the effects of the covariates (age, sex, and perceived health).16–19 Root mean square error of approximation (RMSEA), Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), and Standardized Root Mean Square Residual (SRMR) were all used to assess model fit. RMSEA values of 0.08 or lower, CFI and TLI values of 0.95 or greater, and SRMR values of 0.08 or less are used to indicate good model fit.31 Lastly, post hoc analyses were conducted such that the interactive effects of fatigue severity and fatigue sensitivity on the 5 outcome variables were examined.

Results

Descriptive Statistics

Bivariate correlations are presented in Table 1. Fatigue severity statistically significantly correlated with fatigue sensitivity (r = .35, p < .001), anxiety (r = .31, p < .001), depression (r = .33, p < .001), pain severity (r = .20, p < .001), pain interference (r = .26, p < .001), and pain catastrophizing (r = .31, p < .001). Fatigue sensitivity was statistically significantly correlated with anxiety (r = .46, p < .001), depression (r = .45, p < .001), pain severity (r = .25, p < .001), pain interference (r = .20, p < .001), and pain catastrophizing (r = .49, p < .001).

Table 1.

Bivariate correlations and descriptive statistics for study variables (N = 783).

1. 2. 3. 4. 5. 6. 7. 8. 9. Mean [SD] or N (%)
1. Age -- 43.29 [11.64]
2. Sex (Female) .03 -- 596 (76.1%)
3. Perceived Health −.18*** −.08* -- 38.38 [22.63]
4. Fatigue Severity −.01 .07 −.15*** 5.98 [.63]
5. Fatigue Sensitivity −.32*** −.16*** .06 .35*** -- 29.19 [10.88]
6. Depression −.12** −.04 −.18*** .33*** .45*** -- 11.09 [5.36]
7. Anxiety −.20*** −.04 −.13*** .31*** .46*** .76*** -- 11.02 [4.96]
8. Pain Severity .14*** −.10** −.21*** .20*** .25*** .29*** .31*** -- 23.90 [7.69]
9. Pain Interference .15*** −.06 −.30*** .26*** .20*** .35*** .38*** .69*** -- 14.35 [5.37]
10. Pain Catastrophizing −.07* −.09* −.14*** .31*** .49*** .47*** .48*** .62*** .51*** 10.39 [3.28]
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Note.

*

p<.05,

**

p<.01,

***

p<.001.

Sex coded 0 = male and 1 = female; Perceived Health = 12 Item Short Form Health Survey;21 Fatigue Severity = Fatigue Severity Scale;20 Fatigue Sensitivity = Fatigue Sensitivity Questionnaire;11 Depression = Overall Depression Severity and Impairment Scale;24 Anxiety = Overall Anxiety Severity and Impairment Scale;25 Pain Severity = Brief Pain Inventory-Pain Severity Subscale;26 Pain Interference= Brief Pain Inventory-Pain Interference Subscale;26 Pain Catastrophizing = Pain Catastrophizing Scale-Daily Version.27

Measurement Model

The measurement model provided adequate fit to the data [χ2(801)=3078.55, RMSEA=0.06, 90% CI [0.058, 0.063], SRMR=0.07, CFI=0.90, TLI=0.89]. These results suggest that the observed variables were good indicators of each of the seven latent variables.

Main Effects of Fatigue Severity and Fatigue Sensitivity

The structural model provided adequate fit to the data [χ2(783)=2889.13, RMSEA=0.059, 90% CI [0.056, 0.061], SRMR=0.061, CFI=0.90, TLI=0.89]. After accounting for the effects of the covariates, fatigue severity was a statistically significant predictor for anxiety (β=0.17, SE=0.04, 95% CI [0.10, 0.25], p<.001), depression (β=0.21, SE=0.04, 95% CI [0.13, 0.28], p<.001), pain interference (β=0.15, SE=0.04, 95% CI [0.06, 0.23], p=.001), and pain catastrophizing (β=0.12, SE=0.04, 95% CI [0.0.04, 0.20], p=.003), but not for pain severity (β=0.05, SE=0.04, 95% CI [−0.03, 0.13], p=.251). In addition, fatigue sensitivity was a statistically significant predictor of anxiety (β=0.40, SE=0.04, 95% CI [0.33, 0.48], p<.001), depression (β=0.40, SE=0.04, 95% CI [0.33, 0.47], p<.001), pain severity (β=0.31, SE=0.04, 95% CI [0.23, 0.38], p<.001), pain interference (β=0.25, SE=0.04, 95% CI [0.17, 0.33], p<.001), and pain catastrophizing (β=0.49, SE=0.04, 95% CI [0.42, 0.56], p<.001).

Covariate Effects

In examining the effects of the covariates, age was statistically significantly related to anxiety (β=−0.11, SE=0.04, 95% CI [−0.18, −0.04], p=.002), pain severity (β=0.21, SE=0.04, 95% CI [0.14, 0.28], p<.001), and pain interference (β=0.19, SE=0.04, 95% CI [0.12, 0.26], p<.001). Sex was statistically significantly related to pain severity (β=−0.08, SE=0.04, 95% CI [−0.15, −0.01], p=.023). Finally, perceived health was statistically significantly related to anxiety (β=−0.16, SE=0.03, 95% CI [− 0.22, −0.09], p<.001), depression (β=−0.19, SE=0.03, 95% CI [−0.25, −0.13], p<.001), pain severity (β=−0.20, SE=0.03, 95% CI [−0.26, −0.13], p<.001), pain interference (β=−0.28, SE=0.03, 95% CI [−0.35, −0.22], p<.001), and pain catastrophizing (β=−0.15, SE=0.03, 95% CI [−0.22, −.09], p<.001).

Post Hoc Analyses

Post hoc analyses were conducted to examine the interactive effect of fatigue severity and fatigue sensitivity on anxiety, depression, pain interference, pain severity, and pain catastrophizing. The interactive effect of fatigue severity and fatigue sensitivity significantly predicted anxiety (β =−0.14, SE=0.07, p=.038, 95% CI [−0.27, −0.01]) and depression symptoms (β =−0.22, SE=0.06, p<.001, 95% CI [−0.34, −0.10]). However, the interactive effect did not significantly predict pain interference, pain severity, or pain catastrophizing.

Discussion

Persons with chronic low back pain and severe fatigue experience significant health disparities.5–8 Yet, there is limited work dedicated to understanding underlying factors that may be related to poorer mental health and pain experience among this group. The aim of the current investigation was therefore to explore the role of fatigue severity and fatigue sensitivity in terms of anxiety and depressive symptoms, pain catastrophizing, and pain severity among adults with severe fatigue and chronic low back pain.

Results of the investigation revealed novel findings in relation to mental health and pain experience among adults with chronic low back pain and severe fatigue. As hypothesized, both fatigue severity and fatigue sensitivity were associated with a range of clinically significant psychiatric and pain constructs, including anxiety, depression, pain catastrophizing, pain interference, and pain severity. Specifically, after accounting for the effects of fatigue severity, fatigue sensitivity significantly related to anxiety, depression, pain severity, pain interference and pain catastrophizing. In addition, once the effects of fatigue sensitivity were considered, fatigue severity significantly related to anxiety, depression, pain interference, and pain catastrophizing. However, no significant effects were observed for fatigue severity and pain severity. All effects were evident after controlling for age, sex, and perceived health. These results suggest that sensitivity to fatigue symptoms, rather than the subjective rating of the severity of such symptoms, may be a better predictor of more severe pain among adults with severe fatigue and chronic low back pain. These results add to the extant literature which has tended to focus exclusively on fatigue severity among individuals with chronic low back pain8. Further, past models of pain have hypothesized that fatigue severity may deplete the necessary resources for coping with pain, thereby intensifying the overall pain experience9,10. The current study suggest reactivity to fatigue symptoms may also be a mechanism involved in the exacerbation of pain experience. As this is the first study to explore the utility of fatigue sensitivity in predicting severe pain among a health disparities population, replication and extension of such work is needed.

In addition, post hoc analyses revealed that fatigue sensitivity significantly moderated the relation between fatigue severity and anxiety and depression symptoms. However, no significant effects were evident in predicting pain outcomes. These results suggest that the interactive effect of fatigue severity and fatigue sensitivity is important in predicting mental health outcomes, whereas the main effects are more centrally relevant for pain related outcomes. It is important to note that fatigue severity and fatigue sensitivity synergistically predict greater mental health symptoms at lower levels of fatigue sensitivity, however, the observed effects were positive. Such findings may in part be due to the selected sample, as all individuals endorsed severe fatigue, thus there was restricted variability in the independent variable. Future work may benefit from testing the current model among those with severe fatigue and non-severe fatigue to determine if the above results are consistent.

Although not a primary aim, several observations warrant brief comments. First, in terms of perceived health, the current findings are consistent with past work that suggest lower perceptions of health are clinical correlates of anxiety and depression as well as health impairment.32–34 The current study builds upon past work by extending these findings to adults with chronic low back pain and severe fatigue. although it was employed as a covariate in the current study due to its documented relation with mental and physical health outcomes, future research could usefully seek to explicate the mechanisms underlying perceived health and its negative association with mental health and pain experience among persons with chronic low back pain and severe fatigue. In this way, we could better understand its role in maintenance and treatment processes for this group. Second, age was a statistically significant predictor for anxiety, pain severity, and pain interference. Notably, age was positively associated with pain severity and pain interference, but it displayed a negative association with anxiety. These data suggest that while older adults may experience greater overall pain, younger developmental age may be a risk marker among persons with chronic pain and severe fatigue for more severe anxiety and pain experience. It is possible that younger persons are lacking the knowledge or skills to cope35 with chronic pain and severe fatigue. It is important to note that this study excluded individuals over the age of 64. This decision was made in an attempt to exclude older adults that may be at greater risk for experiencing more serious health concerns due to the natural aging process, however, the current study should be tested among an older adult sample (65 and older) in order to determine the replicability of such findings. Future study may benefit by trying to compare younger versus older adults in terms of mental and physical health to better understand the implications of age for models related to this comorbidity problem.

Clinically, the current investigation may serve to inform the development of specialized interventions for individuals with severe fatigue and chronic low back pain. Specifically, efforts to mitigate negative mental or physical health problems among this population may best be directed towards addressing both fatigue severity and fatigue sensitivity. Past work focused on addressing fatigue has been geared to fatigue severity and using such interventions as physical activity to offset the negative impact of these symptoms for vulnerable groups.36 The current data suggest that there could be additional utility in broadening the focus on fatigue treatment to include a fatigue sensitivity component. For example, psychoeducation and cognitive restructuring focused on reducing fatigue sensitivity may be useful, as it has been found for other clinical populations with related constructs (e.g., anxiety sensitivity;37,38 Future longitudinal research is needed to replicate and extend the current findings.

There are some limitations to the current study that warrant brief comment. First, the data used in the current study was cross-sectional. Thus, no temporal associations between variables can be determined. Future work may benefit from employing a longitudinal approach in order establish the directionality of the effects between fatigue symptoms and mental and physical health among this population. Second, the current sample consisted of primarily white females. Future work should aim to test the observed relations among more ethnically/racially diverse samples and among a greater majority of men to determine if the current results replicate across more diverse samples with a larger percentage of males. Third, the daily version of the pain catastrophizing scale was employed to obtain the current level of catastrophizing symptoms among the sample. However, future work may benefit from collecting information on average pain catastrophizing symptoms as this may provide a more accurate representation of the effect of fatigue severity and fatigue sensitivity on such symptoms broadly. Another limitation that must be considered is the potential for selection bias. Individuals with Qualtrics Panel accounts may be a specific subset of individuals that are motivated to participate in research projects. It is possible that this group may not be representative of all chronic low back pain populations with severe fatigue. Finally, the participants in the current study were not a clinical fatigue sample per se. That is, the participants endorsed severe fatigue using cut-off scores but were not recruited on the basis of a clinical fatigue disorder (e.g., chronic fatigue syndrome). Thus, there may be utility in testing the current model among a specific clinical fatigue condition in future research.

Conclusions

Overall, the current study provides initial support for the role of fatigue severity and fatigue sensitivity in terms of anxiety, depression, pain severity, and pain catastrophizing among adults with co-occurring severe fatigue and chronic low back pain. Future research could build from this work using prospective designs.

Figure 1. Standardized Main Effects Model.

Figure 1.

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Fatigue Severity = Fatigue Severity Scale;20 Fatigue Sensitivity = Fatigue Sensitivity Questionnaire;11 Depression = Overall Depression Severity and Impairment Scale;24 Anxiety = Overall Anxiety Severity and Impairment Scale;25 Pain Sev = Brief Pain Inventory-Pain Severity Subscale;26 Pain Int= Brief Pain Inventory-Pain Interference Subscale;26 Pain Cat = Pain Catastrophizing Scale-Daily Version.27

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