The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: A systematic review
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.
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Fear-avoidance beliefs are consistently associated with a poor prognosis.
“which is consistently associated with a poor prognosis [60,94,95,96].”
From Digital Rehabilitation for Elbow Pain Musculoskeletal Conditions: A Prospective Longitudinal Cohort Study (2022) · cites this paper as [96]
Pain acceptance addresses pain catastrophizing and kinesiophobia.
“pain acceptance addresses: (1) pain catastrophizing, which is an exaggerated cognitive or emotional response to actual or anticipated pain [51-53], and (2) kinesiophobia, which is the avoidance of activities or movements due to excessive anxiety that it will cause pain or injury [54].”
Fear avoidance beliefs have been shown to be associated with worse prognosis in patients with low back pain.
“and worse prognosis in patients with low back pain [53].”
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- Authors
- Wertli, M. M., Rasmussen-Barr, E., Weiser, S., Bachmann, L. M., & Brunner, F.
- Affiliations
- University of Zurich (CH)
- Karolinska Institutet (SE)
- New York University Langone Orthopedic Hospital (US)
- Corresponding author
- Wertli, Maria M.
- Venue
- The Spine Journal
- Publisher
- Elsevier BV
- Published
- 2014-05
- Volume
- 14
- Issue
- 5
- Pages
- 816-836.e4
- ISSN
- 1529-9430 (ISSN-L)
- OpenAlex
- W1991034746
- Cited by
- 479
- References
- 66
- Citations by year
- 2026: 35 · 2025: 28 · 2024: 46 · 2023: 42 · 2022: 52 · 2021: 37 · 2020: 35 · 2019: 51 · 2018: 52 · 2017: 40 · 2016: 33 · 2015: 21 · 2014: 7
- FWCI
- 2.55
- Type
- journal article
- Language
- en
- Update notices
- erratum (2014-08-01)
- Open access
- closed
- Locations
- The Spine Journal (publishedVersion)
- PubMed (publishedVersion)
- Zurich Open Repository and Archive (University of Zurich) (acceptedVersion)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion)
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Health Sciences › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › Medical Practices and Rehabilitation
- Health Sciences › Medicine › Pathology and Forensic Medicine › Spine and Intervertebral Disc Pathology
- Keywords
- fear-avoidance beliefs, non-specific low back pain, prognostic factors, Fear-Avoidance Beliefs Questionnaire, Tampa Scale for Kinesiophobia, subacute low back pain, work-related outcomes, return to work, sick days, disability insurance, chronicity, kinesiophobia
- MeSH terms
- Adaptation, Psychological, Avoidance Learning, Chronic Disease, Fear, Humans, Models, Psychological, Prognosis, Surveys and Questionnaires, Low Back Pain, Observational Studies as Topic
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