Fear-avoidance beliefs in low back pain


Low back pain is one of the most common causes of work absence. There is a growing understanding that fear avoidance behaviours can adversely affect rehabilitation and return to normal activities of daily living.

The fear avoidance model suggests that patients without fear are more likely to confront pain problems and are more active in the coping process.

There has been some debate as to how and when it is best to assess the influence of fear avoidance beliefs (FAB) in clinical practice, and there are no recommendations for the assessment of FAB.

This recent systematic literature review aimed to assess the influence of FAB on the outcome of various treatments in RCTs in patients with low back pain.

Work absence is often caused by low back pain while associated fear avoidance behaviours may adversely affect rehabilitation

Here’s what they did

BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, PubMed/Medline, Scopus, and Web of Science were searched from January 1990 to January 2013 for studies assessing FAB with the most frequently used questionnaires Fear Avoidance Behaviour Questionnaire (FABQ) and Tampa Scale for Kinesiophobia (TSK). FABQ measures fear of pain caused by physical activity, TSK measures fear of movement and re-injury. There is moderate overlap between the two questionnaires. 2,331 matches were considered, 78 full papers assessed but only 18 were included in final analysis.

Methodological quality was assessed using the SIGN checklist and low quality studies excluded from the review. Treatment was categorized into either bio-medical approach e.g. physiotherapy with no cognitive behavioural therapy (CBT), and treatment aimed to address fear avoidance behaviour e.g. psychologically informed physiotherapy.

Here’s what they found

  • Seven out of 9 studies found that those patients with high baseline scores had more pain and /or disability and were less likely to return to work.
  • Three found an association between decreased FAB during treatment with increased return to work, less pain and disability.
  • Two reported that using a graded activity approach only, was less effective in patients with FAB.
  • Two reported combining graded activity and CBT based education (e.g. Back Book) increased efficacy of treatment in those based on bio-medical concepts.

Importantly, the researchers found high levels of FAB in those patients who reported more pain and or disability but when these fears were addressed these findings were improved on follow up. When fears were dealt with and addressed (compared to controls who were treated with typical bio-medical concepts of pain) patients typically were able to return to work more quickly and reported less distress.

Clinically relevant for many physiotherapists, the positive results in terms of less FAB and the positive attributes associated with this was not as consistent in patients who had back pain for greater than six months duration.

The author’s conclusions

Patients with high FAB are more likely to improve when these beliefs are addressed in treatment than when these beliefs are ignored, and treatment strategies should be modified where FAB is present.

When fears were dealt with, patients typically were able to improve and return to work more quickly

When fears were dealt with, patients typically were able to get better and return to work more quickly

The Musculoskeletal Elf’s view

The_Msk_Elf-Twitter_reasonably_smallThere is evidence that psychological factors are important aspects of the management and presentations in mechanical low back pain (Turk & Okifuji, 2002). Structural explanatory models for the management of low back pain have been subjected to scrutiny since there is evidence for low correlation with ongoing back pain and structural abnormalities (such as the findings in MRI scans for example).

Historically the rehabilitation professions have based assessment around problems with postural alignment and other biomechanical factors. This approach to back pain assessment and intervention i.e. finding and ‘treating’ anomalies has come under scrutiny and the somewhat controversial paper by Professor Lederman makes interesting reading (Lederman 2010). It may be relevant to review methods and educational strategies that challenge this ‘structural’ based approach when understanding ongoing back pain, since factors such fear and secondary defensive responses are important considerations.

Positive outcomes were observed in this particular review when FAB were addressed. This may be achieved in a variety of ways depending on the context and manner of the presentation.  Other than formal educational approaches, exercise itself may be considered a form of fear reducing behaviour when movement is approached in supportive manner. Combining movement and education in a process known as cognitive functional therapy is gaining interest and has supportive evidence discussed in this broadcast.

The main ‘take home’ message of this particular review however appears to be that addressing behavioural responses to threat is important and has the most efficacy in those patients presenting relatively early in their presentation.

Practically, in this timeframe physiotherapists are perhaps more likely to influence outcomes in a positive manner. This is an important consideration as most physiotherapists are aware that many patients present or are referred with problems of considerably longer duration than the positive six month period discussed in this paper. Positive responses to therapy are often more difficult to achieve in ongoing pain since; “chronic pain is not the same as acute pain lasting longer.”(Hagena et al., 2000)

Many complex interacting factors may conspire to mitigate success in the treatment of chronic low back pain conditions since the disorder is influenced by many factors which therapists need to consider in the light of evidence from many clinical studies.

What do you think?

  • Is the structural approach to back pain obsolete?
  • How do you address FAB in your practice?

Send us your views on this blog and become part of the ever expanding Musculoskeletal Elf community. Post your comment below, or get in touch via social media (Facebook, Twitter, LinkedIn, Google+).


Wertli, M.M., Rasmussen-Barr E., Held U., Weiser S., Bachmann L.M., Brunner, F. 2014, ‘Fear-avoidance beliefs-a moderator of treatment efficacy in patients with low back pain: a systematic review.’ Spine Journal, Vol. 14, no.11, pp.2658-78 [Abstract]

Turk D.C. Okifuji A. 2002 ‘Factors in Chronic Pain: Evolution and Revolution‘, Journal of Consulting and Clinical Psychology Vol. 70, no. 3, pp. 678–690 (pdf)

Lederman, E. 2010, ‘The fall of the postural–structural–biomechanical model in manual and physical therapies: Exemplified by lower back pain‘ CPDO Online Journal, March, pp.1-14 (pdf)

Hagena,K.B., Bjørndala,A.,  Uhligb,T., Kvienb,T.K. 2000, ‘A population study of factors associated with general practitioner consultation for non-inflammatory musculoskeletal pain’, Ann Rheum Diseases, Vol. 59, pp.788-793

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Ian Stevens

After qualifying as a Physiotherapist I specialised in MSK upper limb disorders which led onto an emerging interest in pain physiology/behaviour at inception of Physiotherapy Pain Association. Working in a pain clinic I developed a special interest in stress biology/pain physiology and pain behaviour. I have contributed to PPA and liaised with leading proponents of this integrated approach such as Louis Gifford. Completing my MA in Medical Humanities via Swansea University greatly influenced my understanding of people and the wider aspects of health care. I am interested in the interface of the arts/science divide –where rational science is encouraged but where people are at the heart of the decision making process. Personal interests are photography www.flickr.com/photos/ianstevens, and learning new things! I play Irish flute , enjoy all outdoor activities and being with my family who are into art, music, good food and being with people who like similar things (sometimes in pubs).

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