A Psychometric Investigation of Fear-Avoidance Model Measures in Patients With Chronic Low Back Pain

Abstract

t he fear-avoidance model of musculoskeletal pain (FAM) has been highlighted as a psychological model of potential importance for rehabilitation. 33 The FAM proposes that during a musculoskeletal pain episode, anxiety, pain-related fear, and pain catastrophizing interact to determine whether an individual will resume normal activities (low psychological distress) or will avoid normal activities due to anticipation of increased pain and/or reinjury (high psychological distress). 33,35,60 The FAM suggests that high psychological distress will be associated with poor clinical outcomes, potentially resulting in depressive symptoms, elevated pain intensity, greater physical impairments, and continued disability. 33,35,60 Evidence supporting validity of the FAM can be found in the clinical studies of low back pain (LBP). Longitudinal studies have indicated that elevated FAM measures were predictive of poor outcomes for individuals with LBP. 2,12,14,44,46,52 Furthermore, effective FAM treatment strategies have been reported, including patient education, 3,5 graded exercise, 13,36 and graded exposure. 6,20,21,37,58,59 While portions of the FAM are well supported in the literature, there are unresolved questions and issues affecting its application in clinical settings. 33One unresolved issue is related to measurement of FAM constructs in outpatient physical therapy settings, which is the focus of this particular study. The FAM is associated with multiple psychological constructs, and there are several available measurement tools. Examples include the Fear-Avoidance Beliefs Questionnaire (FABQ), 61 Fear of Pain Questionnaire (FPQ), 40 Tampa �ca-Tampa �ca-le for Kinesiophobia (T�K), 64 and Pain Catastrophizing �cale (PC�). 49 Typically, psychometric studies incorporate 1 or 2 t sTuDY DesiGn: Validity and test-retest reliability of questionnaires related to the fear-avoidance model (FAM).t oBJeCTiVe: To investigate test-retest reliability, construct redundancy, and criterion validity for 4 commonly used FAM measures.t BaCkGrounD: Few studies have reported psychometric properties for more than 2 FAM measures within the same cohort, making it difficult to determine which specific measures should be implemented in outpatient physical therapy settings.t MeTHoDs: Fifty-three consecutive patients (mean age, 44.3  18.5 years) with chronic low back pain participated in this study. Data were collected with validated measures for FAM constructs, including the Fear-Avoidance Beliefs Questionnaire (FABQ), Fear of Pain Questionnaire (FPQ), Tampa Scale for Kinesiophobia, and Pain Catastrophizing Scale. Validated measures were used to investigate criterion validity of the FAM measures, including the Patient Health Questionnaire for depression, the numerical rating scale for pain intensity, the Physical Impairment Scale for physical impairment, and the Oswestry Disability Questionnaire for self-report of disability. Test-retest reliability of the FAM measures was determined with intraclass correlation coefficients (ICC 2,1 ) for total ...

Effect of Fear-Avoidance Beliefs of Physical Activities on a Model That Predicts Risk-Adjusted Functional Status Outcomes in Patients Treated for a Lumbar Spine Dysfunction

“…As summarized by George et al, 19 when using the complete FABQ-PA, there is evidence indicating that elevated fear-avoidance beliefs can be predictive of poor outcomes for patients with lumbar spine dysfunctions. 12,15,56 In addition, George and Stryker 18 reported that when dichotomizing patients of cervical, upper extremity, lumbar or lower extremity musculoskeletal pain using the psychometric methods described by Hart et al, 29 FABQ-PA was associated with functional outcomes, although patients with elevated FABQ-PA were associated with more functional change compared to those with not-elevated FABQ-PA.…”

“…Long-term studies with large data sets that include many diverse risk adjustment variables should facilitate predictive model development. In addition, as larger, more complex data sets are analyzed, more sophisticated statistical techniques 50,51 may assist the examination of complex associations between different psychosocial measures (eg, George et al's psychometric study of fear-avoidance models) 19 and other clinically appropriate variables.…”

“…There is evidence that identifying patients with elevated fearavoidance beliefs and managing them accordingly may reduce fear and improve outcomes. [3][4][5][10][11][12][13][14][15][16][17][18][19][20]36,40,41,56,68 The purpose of this study was to determine the effect of adding a single-item screening variable that classified patients with elevated versus not elevated fearavoidance beliefs of physical activities on a model that predicts risk-adjusted FS outcomes.…”

Fear-Avoidance Beliefs and Clinical Outcomes for Patients Seeking Outpatient Physical Therapy for Musculoskeletal Pain Conditions

“…21 Fear-avoidance beliefs are a clinical aspect of the FAM that has been previously studied in patients with low back pain. 8,11,13,14,33,35 In cross-sectional studies, patients with elevated fear-avoidance beliefs were more likely to have higher pain and disability scores, even in multivariate analyses that control for potential confounding factors. 14,35 In longitudinal studies, patients with elevated fear-avoidance beliefs were more likely to not return to work 8 and to experience poor treatment outcomes following physical therapy episodes.…”

“…8,11,13,14,33,35 In cross-sectional studies, patients with elevated fear-avoidance beliefs were more likely to have higher pain and disability scores, even in multivariate analyses that control for potential confounding factors. 14,35 In longitudinal studies, patients with elevated fear-avoidance beliefs were more likely to not return to work 8 and to experience poor treatment outcomes following physical therapy episodes. 11,13 Collectively, these studies support the clinical application of the FAM for patients with low back pain.…”