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Predictive validity of initial fear avoidance beliefs in patients with low back pain receiving physical therapy: is the FABQ a useful screening tool for identifying patients at risk for a poor recovery?

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Abstract

Several prospective studies examining patients receiving physical therapy support the predictive validity of FABQ subscale scores. This has lead to the proposition that the FABQ would be a useful screening tool, permitting early identification of patients at risk for a poor outcome with an opportunity to modify the treatment accordingly. However, the predictive validity of the FABQ within physical therapy practice has yet to be examined. Predictive validity was analyzed between the FABQ-PA, FABQ-W using both disability and pain as the dependent variables using Pearson correlation coefficients and stepwise hierarchical linear regression modeling controlling for baseline variables. Separate analyses were run for patients with private health insurance and those receiving workers’ compensation. Further analysis of predictive validity was performed by dichotomizing the outcome of physical therapy. Patients were coded as having a poor outcome if they failed to achieve a minimum clinically important change in disability over the course of treatment. The accuracy of previously reported cut-off scales for both the FABQ-W and FABQ-PA were examined for both payor types. Results of the hierarchical linear regression analyses for patients with private insurance showed neither the FABQ-PA nor the FABQ-W score significantly improved the explained variance in change in pain or disability. For patients receiving workers’ compensation, only the FABQ-W subscale score significantly contributed to the model after controlling for the other baseline variables for both changes in disability and pain. Only the FABQ-W subscale was predictive of poor outcome and this was only identified in the worker’s compensation group. The results suggest that the work subscale of the FABQ might be an appropriate screening tool to identify patients with work-related LBP who are at risk for a poor outcome with routine physical therapy. Neither FABQ subscale was predictive of outcome for patients with private insurance, and the use of the FABQ, as a screening tool for patients with non-work-related LBP was not supported.

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References

  1. Al-Obaidi SM, Beattie P, Al-Zoabi B, Al-Wekeel S (2005) The relationship of anticipated pain and fear avoidance beliefs to outcome in patients with chronic low back pain who are not receiving workers’ compensation. Spine 30:1051–1057

    Article  PubMed  Google Scholar 

  2. Boersma K, Linton S, Overmeer T, Jansson M, Vlaeyen J, de Jong J (2004) Lowering fear-avoidance and enhancing function through exposure in vivo. A multiple baseline study across six patients with back pain. Pain 108:8–16

    Article  PubMed  Google Scholar 

  3. Boersma K, Linton SJ (2005) Screening to identify patients at risk: profiles of psychological risk factors for early intervention. Clin J Pain 21:38–43

    Article  PubMed  Google Scholar 

  4. Buer N, Linton SJ (2002) Fear-avoidance beliefs and catastrophizing: occurrence and risk factor in back pain and ADL in the general population. Pain 99:485–491

    Article  PubMed  Google Scholar 

  5. Burton AK, Waddell G, Tillotson KM, Summerton N (1999) Information and advice to patients with back pain can have a positive effect. A randomized controlled trial of a novel educational booklet in primary care. Spine 24:2484–2491

    Article  PubMed  CAS  Google Scholar 

  6. Carragee EJ, Alamin TF, Miller JL, Carragee JM (2005) Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J 5:24–35

    Article  PubMed  Google Scholar 

  7. Crombez G, Vervaet L, Lysens R, Baeyens F, Eelen P (1998) Avoidance and confrontation of painful, back-straining movements in chronic back pain patients. Behav Modif 22:62–77

    Article  PubMed  CAS  Google Scholar 

  8. Crombez G, Vlaeyen JW, Heuts PH, Lysens R (1999) Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain 80:329–339

    Article  PubMed  CAS  Google Scholar 

  9. Delitto A, Erhard RE, Bowling RW (1995) A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Phys Ther 75:470–485

    PubMed  CAS  Google Scholar 

  10. Fritz JM, George SZ (2002) Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fear avoidance beliefs. Phys Ther 82:973–983

    PubMed  Google Scholar 

  11. Fritz JM, Irrang JJ (2001) A comparison of a modified Oswestry low back disability questionnaire and the Quebec back pain disability scale. Phys Ther 81:776–788

    PubMed  CAS  Google Scholar 

  12. Fritz JM, Delitto A, Erhard RE (2003) Comparison of classification-based physical therapy with therapy based on clinical practice guidelines for patients with acute low back pain: a randomized clinical trial. Spine 28:1363–1371

    Article  PubMed  Google Scholar 

  13. Fritz JM, George SZ, Delitto A (2001) The role of fear-avoidance beliefs in acute low back pain: relationships with current and future disability and work status. Pain 94:7–15

    Article  PubMed  CAS  Google Scholar 

  14. George SZ (2006) Fear: a factor to consider in musculoskeletal rehabilitation. J Orthop Sports Phys Ther 36:264–266

    PubMed  Google Scholar 

  15. George SZ, Fritz JM, Bialosky JE, Donald DA (2003) The effect of a fear-avoidance-based physical therapy intervention for patients with acute low back pain: results of a randomized clinical trial. Spine 28:2551–2560

    Article  PubMed  Google Scholar 

  16. George SZ, Fritz JM, McNeil DW (2006) Fear-avoidance beliefs as measured by the fear-avoidance beliefs questionnaire: change in fear-avoidance beliefs questionnaire is predictive of change in self-report of disability and pain intensity for patients with acute low back pain. Clin J Pain 22:197–203

    Article  PubMed  Google Scholar 

  17. Hanley J, McNeil B, (1982) The meaning and use of the area under receiver operating characteristic (ROC) curve. Radiology 143:29–36

    PubMed  CAS  Google Scholar 

  18. Hicks GE, Fritz JM, Delitto A, McGill SM (2005) Preliminary development of a clinical prediction rule for determining which patients with low back pain will respond to a stabilization exercise program. Arch Phys Med Rehabil 86:1753–1762

    Article  PubMed  Google Scholar 

  19. Jacob T, Baras M, Zeev A, Epstein L (2001) Low back pain: reliability of a set of pain measurement tools. Arch Phys Med Rehabil 82:735–742

    Article  PubMed  CAS  Google Scholar 

  20. Jaeschke R, Guyatt GH, Sackett DL (1994) Users’ guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The evidence-based Medicine Working Group. JAMA 271:703–707

    Article  PubMed  CAS  Google Scholar 

  21. Jellema P, van der Horst HE, Vlaeyen JW, Stalman WA, Bouter LM, van der Windt DA (2006) Predictors of outcome in patients with (sub)acute low back pain differ across treatment groups. Spine 31:1699–1705

    Article  PubMed  Google Scholar 

  22. Jensen MP, Turner JA, Romano JM (1994) What is the maximum number of levels needed in pain intensity measurement? Pain 58:387–392

    Article  PubMed  CAS  Google Scholar 

  23. Klaber Moffett JA, Carr J, Howarth E (2004) High fear-avoiders of physical activity benefit from an exercise program for patients with back pain. Spine 29:1167–1172

    Article  PubMed  Google Scholar 

  24. Klenerman L, Slade PD, Stanley IM, Pennie B, Reilly JP, Atchison LE, Troup JD, Rose MJ (1995) The prediction of chronicity in patients with an acute attack of low back pain in a general practice setting. Spine 20:478–484

    Article  PubMed  CAS  Google Scholar 

  25. Linton SJ (2000) A review of psychological risk factors in back and neck pain. Spine 25:1148–1156

    Article  PubMed  CAS  Google Scholar 

  26. Linton SJ, Hallden K (1998) Can we screen for problematic back pain? A screening questionnaire for predicting outcome in acute and subacute back pain. Clin J Pain 14:209–215

    Article  PubMed  CAS  Google Scholar 

  27. Mannion AF, Junge A, Taimela S, Muntener M, Lorenzo K, Dvorak J (2001) Active therapy for chronic low back pain: part 3. Factors influencing self-rated disability and its change following therapy. Spine 26:920–929

    Article  PubMed  CAS  Google Scholar 

  28. Naylor CD (1995) Grey zones of clinical practice: some limits to evidence-based medicine. Lancet 345:840–842

    Article  PubMed  CAS  Google Scholar 

  29. Obuchowski NA (2003) Receiver operating characteristic curves and their use in radiology. Radiology 229:3–8

    Article  PubMed  Google Scholar 

  30. Pengel HM, Refshauge K, Maher C (2004) Responsiveness of pain, disability, and physical impairment outcomes in patients with low back pain. Spine 29:879–883

    Article  PubMed  Google Scholar 

  31. Phillips HC (1987) Avoidance behaviour and its role in sustaining chronic pain. Behav Res Ther 25:279

    Google Scholar 

  32. Picavet HS, Vlaeyen JW, Schouten JS (2002) Pain catastrophizing and kinesiophobia: predictors of chronic low back pain. Am J Epidemiol 156:1028–1034

    Article  PubMed  Google Scholar 

  33. Pincus T, Vlaeyen JW, Kendall NA, Von Korff MR, Kalauokalani DA, Reis S (2002) Cognitive-behavioral therapy and psychosocial factors in low back pain: directions for the future. Spine 27:E133–E138

    Article  PubMed  Google Scholar 

  34. Poiraudeau S, Rannou F, Baron G, Le HA, Coudeyre E, Rozenberg S, Huas D, Martineau C, Jolivet-Landreau I, Garcia-Mace J, Revel M, Ravaud P (2006) Fear-avoidance beliefs about back pain in patients with subacute low back pain. Pain 124:305–311

    Article  PubMed  CAS  Google Scholar 

  35. Potter RG, Jones JM (1992) The evolution of chronic pain among patients with musculoskeletal problems: a pilot study in primary care. Br J Gen Pract 42:462–464

    PubMed  CAS  Google Scholar 

  36. Rothwell PM (2005) External validity of randomised controlled trials: “to whom do the results of this trial apply?” Lancet 365:82–93

    Article  PubMed  Google Scholar 

  37. Sieben JM, Portegijs PJ, Vlaeyen JW, Knottnerus JA (2005) Pain-related fear at the start of a new low back pain episode. Eur J Pain 9:635–641

    Article  PubMed  Google Scholar 

  38. Sieben JM, Vlaeyen JW, Portegijs PJ, Verbunt JA, van Riet-Rutgers S, Kester AD, Von Korff M, Arntz A, Knottnerus JA (2005) A longitudinal study on the predictive validity of the fear-avoidance model in low back pain. Pain 117:162–170

    Article  PubMed  Google Scholar 

  39. Staal JB, Hlobil H, Twisk JW, Smid T, Koke AJ, van Mechelen W (2004) Graded activity for low back pain in occupational health care: a randomized, controlled trial. Ann Intern Med 140:77–84

    PubMed  Google Scholar 

  40. Swinkels-Meewisse EJ, Swinkels RA, Verbeek AL, Vlaeyen JW, Oostendorp RA (2003) Psychometric properties of the Tampa Scale for kinesiophobia and the fear-avoidance beliefs questionnaire in acute low back pain. Man Ther 8:29–36

    Article  PubMed  CAS  Google Scholar 

  41. Vlaeyen JW, de Jong J, Geilen M, Heuts PH, van Breukelen G (2002) The treatment of fear of movement/(re)injury in chronic low back pain: further evidence on the effectiveness of exposure in vivo. Clin J Pain 18:251–261

    Article  PubMed  Google Scholar 

  42. Vlaeyen JW, de Jong JR, Onghena P, Kerckhoffs-Hanssen M, Kole-Snijders AM (2002) Can pain-related fear be reduced? The application of cognitive-behavioural exposure in vivo. Pain Res Manag 7:144–153

    PubMed  Google Scholar 

  43. Vlaeyen JW, de Jong J, Geilen M, Heuts PH, van Breukelen G (2001) Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain. Behav Res Ther 39:151–166

    Article  PubMed  CAS  Google Scholar 

  44. Waddell G, Newton M, Henderson I, Somerville D, Main CJ (1993) Fear-avoidance beliefs questionnaire and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 52:157–168

    Article  PubMed  CAS  Google Scholar 

  45. Watson PJ, Booker CK, Main CJ (1997) Evidence for the role of psychological factors in abnormal paraspinal activity in patients with chronic low back pain. J Musculoskeletal Pain 4:41–56

    Article  Google Scholar 

  46. Werneke M, Hart DL, Cook D (1999) A descriptive study of the centralization phenomenon. A prospective analysis. Spine 24:676–683

    Article  PubMed  CAS  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Physical Therapy, Physical Therapy Program, Franklin Pierce College, 5 Chenell Drive, Concord, NH, 03301, USA

    Joshua A. Cleland

  2. Rehabilitation Services, Concord Hospital, Concord, NH, USA

    Joshua A. Cleland

  3. Regis University Manual Therapy Fellowship Program, Denver, CO, USA

    Joshua A. Cleland

  4. Division of Physical Therapy, University of Utah, Salt Lake City, UT, USA

    Julie M. Fritz

  5. Intermountain Healthcare, Salt Lake City, UT, USA

    Julie M. Fritz & Gerard P. Brennan

Authors
  1. Joshua A. Cleland
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  2. Julie M. Fritz
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  3. Gerard P. Brennan
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Correspondence to Joshua A. Cleland.

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The handling of data in this study was performed in compliance with the current laws of the United States of America inclusive of ethics approval.

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Cleland, J.A., Fritz, J.M. & Brennan, G.P. Predictive validity of initial fear avoidance beliefs in patients with low back pain receiving physical therapy: is the FABQ a useful screening tool for identifying patients at risk for a poor recovery?. Eur Spine J 17, 70–79 (2008). https://doi.org/10.1007/s00586-007-0511-y

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  • DOI: https://doi.org/10.1007/s00586-007-0511-y

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