PHYSIOTHERAPY THEORY AND PRACTICE

2017, VOL. 33, NO. 8, 653–660

https://doi.org/10.1080/09593985.2017.1331481

DESCRIPTIVE REPORT

Kinesiophobia and maladaptive coping strategies prevent improvements in pain

catastrophizing following pain neuroscience education in fibromyalgia/chronic
fatigue syndrome: An explorative study
Anneleen Malfliet, PT, MSc a,b,c, Jessica Van Oosterwijck, PT, PhD a,b,d, Mira Meeus, PT, PhDa,d,e,
Barbara Cagnie, PT, PhDd, Lieven Danneels, PT, PhDd, Mieke Dolphens, PT, PhDd, Ronald Buyl, PT, PhDf,
and Jo Nijs, PT, PhDa,b,c
a
Pain in Motion Research Group, University of Antwerp, Antwerp, Belgium; bDepartment of Physiotherapy, Human Physiology and Anatomy,
Faculty of Physical Education & Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; cDepartment of Physical Medicine and
Physiotherapy, University Hospital Brussels, Brussels, Belgium; dDepartment of Rehabilitation Sciences and Physiotherapy, Faculty of
Medicine and Health Sciences, Ghent University, Ghent, Belgium; eDepartment of Rehabilitation Sciences and Physiotherapy, Faculty of
Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; fDepartment of Biostatistics and Medical Informatics, Vrije
Universiteit Brussel, Brussels, Belgium

ABSTRACT ARTICLE HISTORY

Many patients with chronic fatigue syndrome(CFS) and/or fibromyalgia(FM) have little understand- Received 8 February 2016
ing of their condition, leading to maladaptive pain cognitions and coping strategies. These should Revised 28 June 2016
be tackled during therapy, for instance by pain neurophysiology education (PNE). Although positive Accepted 31 July 2016
effects of PNE are well-established, it remains unclear why some patients benefit more than others. KEYWORDS
This paper aims at exploring characteristics of patients responding poor to PNE to further improve Chronic fatigue syndrome;
its effectiveness. Data from two RCT’s were pooled to search for baseline predictors. Subjects (n = fibromyalgia; pain
39) suffering from CFS/FM, as defined by the American College of Rheumatology, underwent PNE neuroscience education
treatment. The Pain Catastrophizing Scale (PCS); Pain Coping Inventory (PCI); and Tampa Scale of
Kinesiophobia (TSK) were defined as outcome measures. There was a significant negative relation-
ship between baseline TSK and the change in both PCS total score (r = −0.584; p < 0.001) and PCS
rumination (r = −0.346; p < 0.05). There was a significant negative relationship between the change
in PCS total score and baseline PCI worrying (r = −0.795; p < 0.001) and retreating (r = −0.356;
p < 0.05). FM/CFS patients who tend to worry allot about their pain and with high levels of
kinesiophobia are likely to experience less reductions in catastrophizing following PNE. It seems
that PNE alone is insufficient to reduce catastrophic thinking regarding pain, and supplementary
treatment is needed.

Introduction Additionally, the lack of understanding the nature of their

widespread pain may lead to the development of negative
Chronic fatigue syndrome (CFS) and fibromyalgia (FM)
and maladaptive thoughts, emotions and cognitions, as
are two conditions that share key symptoms like wide-
well as behaviors like catastrophizing, hypervigilance,
spread pain and fatigue and that often occur together
avoidance behavior and somatization (Meeus and Nijs,
(Aaron, Burke, and Buchwald, 2000; Buchwald and
2007), further influencing their pain perception.
Garrity, 1994; Martinez-Martinez et al., 2014). Many
Therefore, it is necessary to tackle these cognitions during
patients diagnosed with one or both conditions suffer
therapy, for instance by providing education (Moseley,
from widespread pain without knowing its underlying
2004). Most of the more “traditional” educational (biome-
cause or mechanisms. Patients who have little or faulty
dical) models that are mainly focusing more on basic
understanding of pain mechanisms seem to define pain
anatomy, biomechanics, pathophysiology, etc. seem to
as more threatening or dangerous due to damage or injury
have limited efficacy in decreasing pain and disability in
(Jackson et al., 2005; Meeus et al., 2010; Van Oosterwijck
chronic pain patients (Cherkin et al., 1996; Parker et al.,
et al., 2011). This perception results in lower pain tolerance,
1984; Roland and Dixon, 1989; Sirles, Brown, and Hilyer,
more catastrophic thoughts regarding pain and the use of
1991). Meanwhile, a systematic review by Louw, Diener,
less adaptive pain coping strategies (Jackson et al., 2005).
Butler, and Puentedura (2011) provided compelling

CONTACT Jo Nijs, PT, PhD jo.nijs@vub.be Department of Physiotherapy, Human Physiology and Anatomy (KIMA), Faculty of Physical Education &
Physiotherapy, Vrije Universiteit Brussel, Medical Campus Jette, Building F-Kine, Laarbeeklaan 103, BE-1090 Brussels, Belgium.
© 2017 Taylor & Francis
654 A. MALFLIET ET AL.
evidence for the positive effects of pain neuroscience edu-
cation (PNE) in reducing pain complaints, disability, cata-
strophizing and improving physical performance in
chronic musculoskeletal disorders. PNE aims to educate
patients about the neurophysiology, neurobiology, proces-
sing and representation of pain. In addition to the review
by Louw, Diener, Butler, and Puentedura (2011), more
recent trials and case reports support the effectiveness of
PNE in different chronic pain populations (Anandkumar,
2015; Anandkumar and Manivasagam, 2014; Louw, 2014;
Louw, Diener, Landers, and Puentedura, 2014; Louw,
Puentedura, and Mintken, 2012; van Ittersum, van
Wilgen, Groothoff, and van der Schans, 2011; Van
Oosterwijck et al., 2013; Zimney, Louw, and Puentedura,
2014). These studies provide additional evidence that PNE
can also reduce the impact of pain and illness in daily life,
and kinesiophobia (fear of movement); as well as improve
illness perceptions, anxiety, and health status.
Although the effects of PNE in the chronic pain
population are well-established, it remains unclear
why some patients benefit more than others.
Exploring baseline (pretreatment) characteristics of
patients that respond poorly to PNE will be important
to further improve this educational strategy and hence
to extend its effectiveness to a larger number of patients
with chronic pain. However, studies examining whether
baseline characteristics predict the outcome following
PNE in chronic pain patients are currently lacking.
For the reasons outlined above, the present study
aimed at exploring baseline factors predicting treat-
ment outcome following PNE in patients with FM/
CFS. Therefore, data from two previously published
randomized controlled clinical trials (RCT’s) (Meeus
et al., 2010; Van Oosterwijck et al., 2013) were pooled
to search for such baseline predictors. Based on our
current knowledge regarding the effectiveness of PNE
and the study of Tan, Teo, Anderson, and Jensen
(2011), it was hypothesized that the presence of mala-
daptive pain cognitions and coping strategies may
predict the treatment outcome following PNE. More
specially, given the nature (Butler and Moseley, 2003)
and rationale (Nijs et al., 2011) of PNE, including
long-term reconceptualization of pain, alterations in
illness beliefs and establishing adaptive pain cogni-
tions, it is hypothesized that patients with more severe
maladaptive pain cognitions and coping strategies pre-
treatment will have a poorer outcome after PNE, as it
will be more challenging to address these maladaptive
pain cognitions and coping strategies in such patients.
Therefore, this paper investigates whether high kine-
siophobia, high catastrophizing and/or maladaptive
coping strategies at baseline are related to poorer
treatment outcome following PNE.
Methods
Setting and patients
The data used in this analysis were obtained by pooling
the data of two preexisting datasets by Van Oosterwijck
et al. (2013) and Meeus et al. (2010), investigating FM and
CFS patients respectively. These datasets were pooled
because of the similarities in both protocols. Moreover,
selection criteria of both CFS and FM were similar in the
two pooled studies, with all included patients suffering
from chronic nonspecific widespread pain, as defined by
the American College of Rheumatology (Wolfe et al.,
1990). Nonspecific was defined as not resulting from an
established medical illness like rheumatoid arthritis nor
any other medical condition. The widespread pain experi-
enced by these patients is likely to result from central
sensitization (Meeus and Nijs, 2007; Nijs et al., 2012;
Staud, Robinson, and Price, 2007).
The initial analysis of both trials focused on the
effectiveness of PNE and are reported elsewhere
(Meeus et al., 2010; Van Oosterwijck et al., 2013).
Both original study protocols were approved by the
ethical committee of the University Hospital Brussels/
Vrije Universiteit Brussel.
Outcome measures
A battery of self-reported questionnaires regarding the
presence of maladaptive cognitions and coping strate-
gies of pain was defined as the outcome measures.
Primary outcome measure
The Pain Catastrophizing Scale (PCS) assesses the pre-
sence and degree of pain catastrophizing. Pain catastro-
phizing was described by Sullivan and Bishop (1995) as
“an exaggerated negative mental set brought to bear
during actual or anticipated painful experience.”
Persons who tend to catastrophize, experience pain as
extremely threatening (Vlaeyen and Crombez, 1999).
Pain catastrophizing may includes three dimensions,
being pain rumination, pain magnification and feeling
helplessness (Sullivan and Bishop, 1995). Pain catastro-
phizing was chosen as primary outcome based on a
theoretic approach, as previous research showed the
importance of pain catastrophizing (measured by the
PCS) in both objectifying treatment effect and predict-
ing long-term pain and functioning (Meeus et al., 2012;
Picavet, Vlaeyen, and Schouten, 2002; Severeijns,
Vlaeyen, van den Hout, and Weber, 2001; Spinhoven
et al., 2004; Sullivan et al., 1998; Sullivan et al., 2001).
The PCS consists of 13 items describing different
thoughts and feelings that individuals may experience

when they are facing pain and provides a general score
and three subscale scores (helplessness, magnification,
rumination). The psychometric properties of the Dutch
version of the PCS, as used here, are well-established. A
Cronbach’s alpha ranging between 0.85 and 0.91 repre-
sents a high reliability, and good validity is reflected in
the high correlation (r = 0.73; p < 0.001) of the PCS
with the subscale “catastrophizing” of the Pain
Cognition List (Crombez, Vlaeyen, Heuts, and Lysens,
1999; Spinhoven et al., 2004; Van Damme et al., 2000).
Secondary outcome measures
The Pain Coping Inventory (PCI) contains 33 items
assessing pain coping strategies. Pain coping strategies
include cognitive and behavioral responses to pain and
can influence pain, functional capacity and psychologi-
cal functioning. These reactions on pain are mostly
grouped under the term “pain coping” and are defined
as attempts to tolerate and handle pain (Brown and
Nicassio, 1987; Jensen, Turner, Romano, and Karoly,
1991). Pain coping strategies can be classified as active
or passive (Kraaimaat and Evers, 2003). Active strate-
gies are used to lighten or control the pain, or to
function despite the pain. When using passive pain
coping strategies, patients show negative thoughts
about pain, avoidance of interference and social with-
drawal (Kraaimaat, Bakker, and Evers, 1997).
Furthermore, these coping strategies can have an adap-
tive or maladaptive influence on pain, physical func-
tioning and psychological functioning, depending on
their immediate or long-term consequences
(Kraaimaat, Bakker, and Evers, 1997).
The PCI assesses six specific pain-coping strategies
that represent two higher-order pain coping dimen-
sions: 1) maladaptive (i.e., worrying, retreating, and
resting) and adaptive (i.e., transformation, distraction,
and reducing demands); and 2) coping (Kraaimaat,
Bakker, and Evers, 1997). Patients were asked to rate
the frequency by which these strategies were used on a
4-point Likert scale ranging from 1 (hardly ever) to 4
(very often). Results of the different subscales were
obtained by taking the mean score of the items belong-
ing to that subscale. A higher score indicated a more
frequent application of that specific coping strategy.
The Dutch version of the PCI has been found to have
sufficient reliability (Crohnbach’s alpha ranging
between 0.42 and .060) (Kraaimaat, Bakker, and Evers,
1997; Kraaimaat and Evers, 2003).
The Tampa Scale of Kinesiophobia (TSK) consists of
17 items to evaluate the presence of kinesiophobia
(Vlaeyen, Kole-Snijders, Boeren, and van Eek, 1995).
Kinesiophobia is defined as the fear of movement and/
or (re-)injury and is a specific type of fear or avoidance
PHYSIOTHERAPY THEORY AND PRACTICE 655
behaviour that can be described as an unusual, irra-
tional and debilitating fear for physical movement and
activity (Kori, Miller, and Todd, 1990). The TSK-Dutch
version used in this study has been shown to have good
reliability (alpha ranging from 0.70 to 0.83) and mod-
erate validity (significant Pearson correlations of TSK
with PCS, Beck Depression Inventory and Fear Survey
Schedule; r(s) =0.33 to 0.59, p < 0.01) (Crombez,
Vlaeyen, Heuts, and Lysens, 1999; Goubert et al.,
2004; Nederhand et al., 2004; Swinkels-Meewisse
et al., 2003; Vlaeyen, Kole-Snijders, Boeren, and van
Eek, 1995).
Van Oosterwijck et al. (2013) obtained these data at
two moments post-therapy (1 week and 3 months fol-
lowing completion of the PNE therapy). For the current
analysis, the data obtained at 1 week post-therapy was
used, in order to fit well with the data used in the study
by Meeus et al. (2010), which was obtained immediately
following the completion of PNE.
Intervention
The PNE session comprised a one-on-one educational
session about the neurophysiology of pain. This included
education regarding the physiology of the nervous system
in general and of the pain system in particular. PNE
focused on informing the patient about the difference
between “nociception” and “pain” and taught patients
that the central nervous system has the ability to increase
or decrease its sensitivity (neuroplasticity) (Nijs et al.,
2011). Attention was given to the fact that the human
body can both amplify and mute pain (e.g., by either
focusing on pain or rather shifting attention from the
pain). This approach aims to help patients cope with
persistent pain (Louw, Diener, Butler, and Peuntedura,
2011). The content of the education sessions was based on
the book “Explain Pain” by Butler and Moseley (2003).
Further details regarding this intervention are presented
elsewhere (Meeus et al., 2010; Nijs et al., 2011; Van
Oosterwijck et al., 2011; Van Oosterwijck et al., 2013).
In the study by Meeus et al. (2010), the intervention
was limited to one individual session of 30 minutes. In
the study by Van Oosterwijck et al. (2013), the inter-
vention was spread out over 7 days and comprised one
individual session of 30 minutes, written information at
home, and one individual session conducted by tele-
phone. During the latter study, patients were motivated
to apply their new insights into their daily life. The
telephone session was used to elucidate any remaining
questions and misunderstandings which existed follow-
ing the oral and written education. In both studies, the
educational sessions were led by individuals with a
Bachelor’s degree in Physiotherapy.
656 A. MALFLIET ET AL.
Statistical analysis
All data were analyzed using IBM SPSS Statistics 22.0 for
Windows (IBM Corporation, Somers, NY). Normality of
the variables was tested with the Kolmogorov–Smirnov
test. The original pooled data consisted of a control group
and an experimental group. As this study aims at exploring
the baseline predictors of PNE treatment, only the experi-
mental (PNE) group was used in this analysis. Correlations
were performed between the change in the primary out-
come factor (PCS) and the baseline measurements of all
other factors, being age, sex, PCI and TSK. Pearson’s cor-
relation analysis was used for data with normal distribu-
tion, Spearman’s correlation analysis for the data that were
not normally distributed.
Results
This study included 39 patients with CFS or FM, with an
age ranging from 18 to 65. Detailed information on the
included subjects can be found in Table 1. The study by
Van Oosterwijck et al. (2013) made use of the intention-to-
treat principle, using the last-observation-carried-forward
approach for two subjects. The study by Meeus et al. (2010)
did not use this principle, which resulted in losing two
subjects to follow-up.
There was a significant negative relationship between
baseline TSK and the change in both PCS total score (r =
−0.584; p < 0.001) and PCS rumination (r = −0.346; p <
0.05). There was also a significant negative relationship
between the change in PCS total score and baseline PCI
worrying (r = −0.795; p < 0.001) and retreating (r = −0.356;
p < 0.05). Last, age was related to the change in PCS
magnification (r = 0.395; p < 0.05). All correlations can be
found in Table 2, inclusive of their significance levels and
confidence intervals.
Discussion
This exploratory study aimed at searching possible predict-
ing baseline factors of treatment outcome when using PNE
in FM/CFS patients. Based on the findings of this additional
analysis of the pooled data from two previously published
RCT’s regarding PNE in patients with FM/CFS, several
preliminary assumptions can be made. First, it seems likely
that patients with higher levels of kinesiophobia
Table 1. Subjects’ characteristics.
Characteristics Meeus et al. (2010)
Subjects n = 24
Sex 2 men; 22 women
Age (mean ± SD) 38.3 ± 10.6
demonstrate less reduction in pain catastrophizing (PCS
total) and ruminating about pain (PCS rumination) in
response to PNE. Second, the use of negative, maladaptive
coping strategies such as avoiding negative environmental
stimuli (PCI retreating) and more worrying about pain
(PCI worrying), appears to be related to less reduction in
catastrophizing following PNE. Last, these results seem to
indicate that the older the patients with FM and CFS, the
more they experience reductions in magnification of the
obnoxious character of pain (PCS magnification) by PNE
treatment. In summary, it appears that FM/CFS patients
who display higher levels of kinesiophobia and worrying
about pain experience less reduction in catastrophizing and
ruminating following PNE. The present results seem to
imply that in patients with CFS/FM with high levels of
kinesiophobia and worrying, PNE on its own seems insuf-
ficient to reduce pain catastrophizing compared to those
with lower levels of kinesiophobia and worrying.
Supplementary therapy may be necessary to address these
elements (e.g., graded exposure/activity techniques, cogni-
tion-targeted exercises, commitment and acceptance ther-
apy, or other cognitive behavioral techniques). However, as
this comprises an explorative study, it needs to be stressed
that these results are preliminary and that no harsh con-
clusions should be drawn.
Currently, studies regarding pain cognitions and coping
strategies as possible predicting factors for PNE therapy in
FM and CFS are essentially lacking, being an argument for
the necessity of this explorative study. Nevertheless, studies
investigating other predictors in prospective studies are
fairly well presented. Recently, de Rooij et al. (2013) pub-
lished a review on predictors of treatment response to
multidisciplinary therapy in FM. Many factors were deter-
mined to predict poorer outcome, like pain, depression,
negative demographic and clinical factors, maladaptive
cognitive and emotional factors and physical functioning.
Additionally, Huibers et al. (2004) determined older age,
exhaustion, female sex, low education level, number of
visits to the general practitioner, low self-perceived activity
level, higher anxious level and bad self-rated health as
general predictors of poorer outcome. Ray, Jefferies, and
Weir (1997) added longer illness duration, subjective cog-
nitive difficulty and somatic symptoms to this list. On the
other hand, they found no predictive influence of anxiety,
depression or general emotional distress (Ray, Jefferies, and
Weir, 1997). Other studies found prediction of poor
Van Oosterwijck et al. (2013) Pooled data
n = 15 n = 39
3 men; 12 women 5 men; 34 women
45.8 ± 9.5 41.2 ± 10.7
 PHYSIOTHERAPY THEORY AND PRACTICE 657

Table 2. Predictors of treatment outcome following PNE.

Outcome measurement Baseline measurement Correlation coefficient Confidence interval
ΔPCS Total Age 0.208 [−.119; .513]
Sex −0.010 [11.36; 16.59]
TSK −0.584*** [−.776; −.323]
PCI Transformation −0.249 [−.527; .080]
PCI Distraction 0.035 [−.285; .397]
PCI Reducing demands −0.119 [−.39; .226]
PCI Retreating −0.356* [−.620; −.055]
PCI Worrying −0.795 *** [−.913; −.607]
PCI Resting −0.167 [−.490; .204]
ΔPCS Helplessness Age 0.261 [−.070; .541]
Sex −0.010 [2.14; 4.16]
TSK 0.026 [−.313; .313]
PCI Transformation −0.038 [*.337; .286]
PCI Distraction −0.250 [−.470; −.011]
PCI Reducing demands −0.245 [−.510; .094]
PCI Retreating −0.297 [−.568; .025]
PCI Worrying −0.066 [−.372; .267]
PCI Resting −0.153 [−.463; .162]
ΔPCS Magnification Age 0.395* [.040; .679]
Sex −0.302 [.970; 2.11]
TSK −0.107 [−.503; .238]
PCI Transformation −0.242 [−.550; .059]
PCI Distraction 0.098 [−.227; .429]
PCI Reducing demands −0.289 [−.523; .047]
PCI Retreating −0.133 [−.426; .170]
PCI Worrying −0.213 [−.515; .104]
PCI Resting 0.114 [−.230; .398]
ΔPCS Rumination Age 0.235 [−.094; .545]
Sex 0.003 [1.51; 3.00]
TSK −0.346* [−.649; .019]
PCI Transformation 0.090 [−.256; .442]
PCI Distraction −0.039 [−.330; .260]
PCI Reducing demands −0.054 [−.378; .269]
PCI Retreating −0.279 [−.615; .074]
PCI Worrying −0.231 [−.541; .111]
PCI Resting −0.092 [−.412; .249]
TSK = Tampa Scale for Kinesiophobia; PCS = Pain Catastrophizing Scale; PCI = Pain Coping Inventory;
ΔPCS = difference in PCS between post-treatment and baseline measurement.
* p < 0.05; ** p < 0.01; *** p < 0.001.

outcome in CFS by being member of a self-help group,
being in receipt of sickness benefit, passive activity pattern
and higher level of depression (Bentall, Powell, Nye, and
Edwards, 2002; Prins et al., 2002).
Although there are some general predictors investi-
gated in the studies presented above, there has been no
attention the role pain cognitions and coping strategies
in this area of research, while this might be pertinent
for optimizing treatment outcomes after PNE, given the
established importance of pain cognitions and coping
strategies in patients with CFS/FM (Garcia-Campayo
et al., 2009; Giesecke et al., 2003; Nielson and Jensen,
2004). The present study tries to address this short-
coming in a first explorative way, and it would be
interesting to have a further look on these and other
factors in subsequent studies, especially given the
important suggestive findings reported here. Based on
our findings, it seems plausible that pain cognitions and
coping strategies have a role in treatment outcome (e.g.,
catastrophizing) following PNE in patients with FM/
CFS, and further studies using larger numbers of sub-
jects, using more and different measurements and using
more appropriate study protocols, are warranted to
confirm this assumption.
The current study findings are important as they
provide the initial step in further exploring predictive
factors of treatment outcome after PNE and offer
important directions for further improving PNE for
patients with FM/CFS. However, the results should
be interpreted in the light of some study limitations.
These include the limited sample size, despite the
pooling of data from two trials, and the limited num-
ber of identical outcome measures used in the original
RCT’s. The limited sample size made it impossible to
use a regression analysis. This could have been
addressed by implementing the study by van
Ittersum, van Wilgen, Groothoff and van der Schans
(2011), if this study had not been conceptually differ-
ent by using only written education. As we wanted to
focus on PNE delivered by a therapist, this data could
not be used. Additionally, as described above, there are
many predictors identified for treatment types other
than PNE. It can be listed as a limitation of this study
that we did not included these predictors here, but, as
658 A. MALFLIET ET AL.
this paper, was intended purely as explorative the data
were limited to this extend. It is also necessary to point
out that the pain coping strategy worrying (PCI wor-
rying) and the pain catastrophizing dimension rumi-
nation (PCS rumination) are based on an overlapping
concept, which might explain the observed association.
Besides this, also the differences between the two
interventions and the different time points utilized in
the two pooled studies (i.e., immediately following
PNE and 1 week following PNE) should be empha-
sized. Nevertheless, as this was a first attempt to deter-
mine predictive factors of PNE therapy based on
previous, available studies, we could not control for
this limitations. An additional limitation can be found
in the fact that the study findings presented here apply
only to patients with FM/CFS and cannot be general-
ized to all patients with chronic pain.
Conclusion
Patients with FM and CFS who tend to worry allot about
their pain and have high levels of kinesiophobia are likely to
experience less reduction in catastrophizing following PNE.
It seems that PNE in this case is insufficient to reduce
catastrophic thinking regarding pain compared to those
with lower levels of kinesiophobia and worrying. In such
cases, it may be necessary to provide supplementary treat-
ment if it is desired to reduce the degree of kinesiophobia
and pain catastrophizing. Treatment strategies such as
graded exposure, etc. have been shown to be effective to
address this. Based on our findings, it seems plausible that
pain cognitions and coping strategies will have a role in
treatment outcome (e.g., catastrophizing) following PNE in
patients with FM/CFS, and further studies using larger
numbers of subjects and more/other measurements are
warranted to confirm this assumption.
Declaration of interest
The authors report no declarations of interest.
Funding
Anneleen Malfliet is a PhD research fellow of the Agency for
Innovation by Science and Technology (IWT)—Applied
Biomedical Research Program (TBM), Belgium. Jessica Van
Oosterwijck is a postdoctoral research fellow funded by the
Special Research Fund of Ghent University. Jo Nijs is holder
of the Chair “Exercise immunology and chronic fatigue in
health and disease” funded by the European College for
Decongestive Lymphatic Therapy, The Netherlands.
ORCID
Anneleen Malfliet http://orcid.org/0000-0003-0598-7038
Jessica Van Oosterwijck http://orcid.org/0000-0002-8946-
4383
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