Identifying patient fear-avoidance beliefs by physical therapists managing patients with low back pain

J Orthop Sports Phys Ther. 2010 Dec;40(12):774-83. doi: 10.2519/jospt.2010.3381. Epub 2010 Oct 22.


Study design: Cross-sectional.

Objectives: To evaluate the accuracy with which physical therapists identify fear-avoidance beliefs in patients with low back pain by comparing therapist ratings of perceived patient fear-avoidance to the Fear-Avoidance Beliefs Questionnaire (FABQ), Tampa Scale of Kinesiophobia 11-item (TSK-11), and Pain Catastrophizing Scale (PCS). To compare the concurrent validity of therapist ratings of perceived patient fear-avoidance and a 2-item questionnaire on fear of physical activity and harm, with clinical measures of fear-avoidance (FABQ, TSK-11, PCS), pain intensity as assessed with a numeric pain rating scale (NPRS), and disability as assessed with the Oswestry Disability Questionnaire (ODQ).

Background: The need to consider psychosocial factors for identifying patients at risk for disability and chronic low back pain has been well documented. Yet the ability of physical therapists to identify fear-avoidance beliefs using direct observation has not been studied.

Methods: Eight physical therapists and 80 patients with low back pain from 3 physical therapy clinics participated in the study. Patients completed the FABQ, TSK-11, PCS, ODQ, NPRS, and a dichotomous 2-item fear-avoidance screening questionnaire. Following the initial evaluation, physical therapists rated perceived patient fear-avoidance on a 0-to-10 scale and recorded 2 influences on their ratings. Spearman correlation and independent t tests determined the level of association of therapist 0-to-10 ratings and 2-item screening with fear-avoidance and clinical measures.

Results: Therapist ratings of perceived patient fear-avoidance had fair to moderate interrater reliability (ICC2,1 = 0.663). Therapist ratings did not strongly correlate with FABQ or TSK-11 scores. Instead, they unexpectedly had stronger associations with ODQ and PCS scores. Both 2-item screening questions were associated with FABQ-physical activity scores, while the fear of physical activity question was also associated with FABQ-work, TSK-11, PCS, and ODQ scores.

Conclusion: Therapists' ratings of perceived patient fear-avoidance were not associated with self-reported fear-avoidance scores, showing a potential disconnect between therapist judgments and commonly used fear-avoidance measures. Instead, therapist ratings had small but statistically significant correlations with pain catastrophizing and disability, findings that may support therapists' inability to discriminate fear-avoidance from these other factors. The 2-item screening questions based on fear of physical activity and harm showed potential to identify elevated FABQ physical activity scores.

Level of evidence: Differential diagnosis, level 2b.

Publication types

  • Multicenter Study

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Bayes Theorem
  • Catastrophization
  • Cross-Sectional Studies
  • Disability Evaluation
  • Disabled Persons / psychology*
  • Fear / psychology*
  • Humans
  • Low Back Pain / diagnosis*
  • Low Back Pain / psychology*
  • Low Back Pain / rehabilitation
  • Middle Aged
  • Pain Measurement
  • Reproducibility of Results
  • Severity of Illness Index
  • Surveys and Questionnaires