Elsevier

The Spine Journal

Volume 14, Issue 5, 1 May 2014, Pages 816-836.e4
The Spine Journal

Review Article
The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review

https://doi.org/10.1016/j.spinee.2013.09.036Get rights and content

Abstract

Background context

Psychological factors including fear avoidance beliefs are believed to influence the development of chronic low back pain (LBP).

Purpose

The purpose of this study was to determine the prognostic importance of fear avoidance beliefs as assessed by the Fear Avoidance Beliefs Questionnaire (FABQ) and the Tampa Scale of Kinesiophobia for clinically relevant outcomes in patients with nonspecific LBP.

Design/setting

The design of this study was a systematic review.

Methods

In October 2011, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, PubMed/Medline, Scopus, and Web of Science. To ensure the completeness of the search, a hand search and a search of bibliographies was conducted and all relevant references included. A total of 2,031 references were retrieved, leaving 566 references after the removal of duplicates. For 53 references, the full-text was assessed and, finally, 21 studies were included in the analysis.

Results

The most convincing evidence was found supporting fear avoidance beliefs to be a prognostic factor for work-related outcomes in patients with subacute LBP (ie, 4 weeks–3 months of LBP). Four cohort studies, conducted by disability insurance companies in the United States, Canada, and Belgium, included 258 to 1,068 patients mostly with nonspecific LBP. These researchers found an increased risk for work-related outcomes (not returning to work, sick days) with elevated FABQ scores. The odds ratio (OR) ranged from 1.05 (95% confidence interval [CI] 1.02–1.09) to 4.64 (95% CI, 1.57–13.71). The highest OR was found when applying a high cutoff for FABQ Work subscale scores. This may indicate that the use of cutoff values increases the likelihood of positive findings. This issue requires further study. Fear avoidance beliefs in very acute LBP (<2 weeks) and chronic LBP (>3 months) was mostly not predictive.

Conclusions

Evidence suggests that fear avoidance beliefs are prognostic for poor outcome in subacute LBP, and thus early treatment, including interventions to reduce fear avoidance beliefs, may avoid delayed recovery and chronicity.

Introduction

Low back pain (LBP) is a pain not attributed to a recognizable pathology. The lifetime prevalence for acute LBP exceeds 80% [1]. Although the overall prognosis is benign, 10% to 15% of these patients develop chronic LBP. This small percentage accounts for three-quarters of the total direct and indirect costs of medical care and lost productivity associated with LBP [2]. There is a consensus in the literature to use a wait-and-see strategy in acute LBP to avoid overtreatment [3]. However, pain that persists beyond the acute stage is an indication for the development of chronic LBP, a condition for which complete recovery and return to 100% function are often difficult to achieve [4]. Current research aims at identifying subgroups at risk for delayed recovery in patients with subacute LBP (>4 weeks) to optimize treatment. Timely initiated and targeted multifaceted treatments in patients at risk for delayed recovery have shown health care cost reductions and tend to facilitate recovery [5].

Psychological factors are believed to influence the development of chronic LBP. The Fear Avoidance Model is used widely to explain how psychological factors affect the experience of pain, and the development of chronic pain and disability [6]. It is theorized that for some individuals with LBP, negative beliefs about pain and/or negative illness information leads to a catastrophizing response in which the worst possible outcome is imaged. This leads to fear of activity and avoidance, which in turn causes disuse and resultant distress, reinforcing the original negative appraisal in a deleterious cycle [6]. The Fear Avoidance Model suggests that patients without fear avoidance beliefs are more likely to confront pain problems and are more active in the coping process. This type of “good” coping has been used to develop interventions for those with high fear avoidance beliefs.

Although the Fear Avoidance Model is generally accepted, it is a matter of debate regarding how and when it is best to assess fear avoidance beliefs in clinical practice. Current treatment guidelines for LBP recommend the timely identification and initiation of multidisciplinary treatment for other psychological factors (eg, depression, distress, job dissatisfaction) associated with increased risk for delayed recovery [3], [7], [8]. Whether and how fear avoidance beliefs should be assessed specifically remains unclear. Many questionnaires have been developed to identify fear avoidance beliefs. The two most commonly used are the Fear Avoidance Questionnaire (FABQ [9]) and the Tampa Scale of Kinesiophobia (TSK; Miller RP, unpublished, 1991) [10]. Their usefulness for detecting fear avoidance beliefs that influence the transition from acute to chronic LBP is not clearly determined and has been debated in the literature [11], [12], [13], [14], [15].

To date, the role of fear avoidance beliefs identified by the FABQ or TSK as prognostic factors for LBP has not been reviewed systematically. The aim of this systematic review is twofold. First, we review the existing literature on the role of fear avoidance beliefs as a prognostic factor in acute, subacute, and chronic LBP. Second, we analyze the available data in terms of an optimal cutoff value for the FABQ and the TSK.

Section snippets

Methods

These systematic reviews followed the recommendation of the Meta-analysis of Observational Studies in Epidemiology statement (Fig. 1) on conducting systematic reviews of observational studies [16].

Study selection

The search and inclusion process is summarized in Fig. 1. Of 2,032 records, 53 were reviewed in full text. The full text assessment using the inclusion and exclusion criteria resulted in the exclusion of 32 studies. The main reasons for exclusion were not investigating fear avoidance beliefs as a prognostic factor, use of questionnaires other than the FABQ and TSK, a follow-up of less than 3 months, and poor study quality. Two studies were excluded because they investigated the prevalence of

Main findings

In this systematic review of 21 observational studies, we found convincing evidence that high fear avoidance beliefs—and work beliefs, in particular—in patients with subacute LBP are prognostic for poor work-related outcomes. High fear avoidance beliefs in patients with LBP for more than 3 months or less than 2 weeks were less associated with poor outcome. Neither the FABQ nor the TSK can be recommended over the other. Both scales used in the subacute population were mainly prognostic, whereas

Conclusion

Evidence suggests that fear avoidance beliefs are prognostic for poor outcome in patients with subacute LBP and should be addressed in this population to avoid delayed recovery.

Acknowledgments

This study was performed in collaboration with many experienced researchers and clinicians. The authors thank the research team of the Occupational and Industrial Orthopaedic Center (OIOC), New York University (NYU) Langone Medical Center in New York for their very valuable discussions and input. Thanks are extended to Reto Kofmehl from Horten Centre of patient oriented research, University of Zurich, Switzerland for compiling the figures.

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    FDA device/drug status: Not applicable.

    Author disclosures: MMW: Nothing to disclose. ER-B: Nothing to disclose. SW: Nothing to disclose. LMB: Nothing to disclose. FB: Nothing to disclose.

    This study was not funded and the authors have no conflict of interest to declare.

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