What is Fear-Avoidance?
Fear-avoidance refers to a model where fears and catastrophizing lead to avoidance of certain movements and activities that in turn heighten an individual’s perception of pain and reduced function. Unfortunately, it is these thoughts that can result in a vicious cycle where pain triggers fear and catastrophization, leading to fear of re-injury and eventually activity avoidance, disuse, depression, and long term disability.
The Fear-Avoidance Belief Questionnaire (FABQ)
The FABQ is a clinical assessment tool to identify individuals with fear-avoidant beliefs early in the hope of avoiding long term disability. The instrument consists of two subscales, a four-item physical activity subscale (FABQ-PA), and a seven-item work subscale (FABQ-W). Each item is scored from 0 to 6 and summed to produce the subscale score.
- FABQ-W score > 29 was most predictive of difficulty returning to work status after four weeks of physiotherapy (2).
- FABQ-PA cut-off score > 13 are more likely to benefit from an exercise program or cognitive-behavioral strategies instead of traditional physiotherapy care (3).
When is the FABQ useful? Does the “funder” of treatment play a role?
Cleland et al. (2007) investigated the predictive validity of the FABQ tool separately for patients with private health insurance and those receiving workers’ compensation for individuals experiencing LBP (4). The results of this study suggest the validity of the FABQ subscale scores is largely dependent on “funding source” and the FABQ subscale used. Among patients receiving workers’ compensation, the initial FABQ-W score, was highly correlated with the final pain and disability scores (4). The predictive value of the FABQ-PA among patients receiving workers’ compensation was not as strong. Neither FABQ subscale score demonstrated predictive validity for patients with private health insurance (4). Table 1 represents the sensitivity, specificity and the positive and negative likelihood ratios values for the FABQ-PA and PABQ-W subscales for private health insurance and worker’s compensation funding.
Table 1: Predictive value of the FABQ-PA and FABQ-W (4)
Other Clinical Assessment Measures of Fear-Avoidance
Examples of clinical outcomes measure to assess fear-avoidance include: the Fear-Avoidance Beliefs Questionnaire (FABQ), Fear of Pain Questionnaire (FPQ), Tampa Scale for Kinesiophobia (TSK), and Pain Catastrophizing Scale (PCS). A recent study by George et al. (2010) investigated the test-retest reliability, construct redundancy, and criterion validity for four commonly used fear-avoidance measures with respect to patients experiencing low back pain (5). They suggest that the four commonly used fear-avoidance measures had similar test-retest stability estimates and shared low to moderate amounts of variance with each other (5). They recommend that physiotherapy outpatient settings may wish to use the PCS for emotional function and the FABQ for pain intensity and physical functioning (5).
References
- Linton S, Vlaeyen J, and Ostelo R. (2002) The Back Pain Beliefs of Health Care Providers: Are We Fear-Avoidant? Journal of Occupational Rehabilitation.12: 4. 223-232
- 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
- 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
- Cleland J, Fritz J, Brennan G. (2008). Predictive validity of initial fear avoidance beliefs in patients with low back pain receiving physiotherapy: is the FABQ a useful screening tool for identifying patients at risk for a poor recovery? Eur Spine J. 17:70–79
- George S, Valencia C, Beneciuk J. (2010) A Psychometric Investigation of Fear-Avoidance Model Measures in Patients With Chronic Low Back Pain. JOSPT. 40:4. 197-205