Identifying Patient Fear-Avoidance Beliefs by Physical ... - JOSPT

The costs of chronic low back 

pain to industrialized 

nations in terms of 

disability and financial 

costs are substantial. 43 Identifying 

which patients are at risk for 

becoming disabled with chronic 

low back pain is, therefore, of 

great importance. 18 Psychosocial 

factors have shown some ability 

to predict chronic disability 

from low back pain, whereas 

patient characteristics, clinical 

examination findings, and 

imaging studies appear to be less 

predictive. 6,8,18 Cross-sectional and prospective 

studies have shown a strong relationship 

with elevated fear-avoidance 

beliefs and disability in patients with 

acute and chronic low back pain. 5,8,13,19,21,2 

3,32,39,42,59,61 Identification of elevated fearavoidance 

beliefs is, therefore, a potentially 

important aspect to consider when 

evaluating patients with low back pain. 

Elevated fear-avoidance beliefs are 

a maladaptive emotional response toward 

an excessive fear of pain that can 

eventually lead to avoidance behavior. 41 

Fear-avoidance beliefs are used in clinical 

prediction rules and can be used to 

guide decision making about biopsycho- 

[ research report ] 

DARREN Q. CALLEY, PT, DScPT, OCS1 • Steven JackSon, PT, MSPT2 • HeatHer collinS, PT, DPT3 • Steven Z. GeorGe, PT, PhD 4 

Identifying Patient Fear-Avoidance 

Beliefs by Physical Therapists Managing 

Patients With Low Back Pain 

social physical therapy approaches. 

9,11,30,21,37,38 Two self-report 

questionnaires that have been 

validated for quantifying fear- 

t Study deSiGn: Cross-sectional. 

t 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). 

t 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. 

t 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 

1 Outpatient Clinical Education Coordinator, Instructor in Physical Therapy, College of Medicine, Mayo Clinic, Rochester, MN. 2 Clinic Director, Hammond Clinic, St John, IN. 3 Staff 

Physical Therapist, Mayo Clinic Arizona, Scottsdale, AZ. 4 Associate Professor, Department of Physical Therapy, Center for Pain Research and Behavioral Health, University of 

Florida, Gainesville, FL. This study was approved by The Institutional Review Board at Mayo Clinic and by The Institutional Review Board at the University of Maryland. At the time 

of the study, the primary author was completing a final project for a Doctor of Science in Physical Therapy degree through the University of Maryland. Address correspondence 

to Dr Darren Calley, 200 1st St SW, Rochester, MN 55904. E-mail: dcalley@mayo.edu 

774 | december 2010 | volume 40 | number 12 | journal of orthopaedic & sports physical therapy 

avoidance beliefs are the Fear- 

Avoidance Beliefs Questionnaire 

(FABQ) and the Tampa Scale 

for Kinesiophobia (TSK). 54,58,61 

of association of therapist 0-to-10 ratings and 

2-item screening with fear-avoidance and clinical 

measures. 

t reSultS: Therapist ratings of perceived patient 

fear-avoidance had fair to moderate interrater 

reliability (ICC = 0.663). Therapist ratings did not 

2,1 

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. 

t 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. 

t level oF evidence: Differential diagnosis, 

level 2b. J Orthop Sports Phys Ther 

2010;40(12):774-783. doi:10.2519/jospt.2010.3381 

t key WordS: FABQ, low back pain, screening

The TSK and FABQ address similar 

avoidance-related constructs and correlation 

between the 2 scales is moderately 

strong. 54 Pain catastrophizing, the tendency 

to fear the worst, is a psychological 

construct related to fear-avoidance and 

is also associated with disability, physical 

activity, and quality of life in patients 

with chronic low back pain. 15,56 Decreasing 

patient catastrophizing has been advocated 

to mediate improved functioning 

in patients with chronic low back pain. 49 

While it is clear that identifying psychosocial 

factors in patients with low 

back pain is important, each questionnaire 

utilized in practice increases patient 

and clinician burden, and the number 

of available questionnaires continues to 

grow. 29,31,54 Streamlined identification of 

patients with elevated fear-avoidance beliefs 

would decrease patient and clinician 

burden and likely improve therapist utilization 

of a fear-avoidance screening tool. 

Additionally, physical therapists may believe 

that identifying fear-avoidance beliefs 

during the clinical exam is intuitive, 

as several factors observed during the 

clinical exam have been found to correlate 

with fear-avoidance scores. 2,3,12,13,20,23,48,55,58 

Experienced physical therapists may 

feel that they are able to discern which 

patients have elevated fear-avoidance 

beliefs without administering validated 

self-report questionnaires. 

Two possible methods to streamline 

identification of elevated fear-avoidance 

beliefs are item and clinician driven. 

Identifying statistically meaningful items 

from existing fear-avoidance questionnaires 

in a large cohort has already been 

reported. Hart et al 29 identified single 

items from the FABQ that classified elevated 

(higher than median scores) physical 

activity or work fear-avoidance more 

than 90% of the time. A few studies have 

examined clinician-driven methods to 

identify patient psychosocial attributes. 

Haggman et al 27 found that physical 

therapists were not able to accurately 

identify depression based on the clinical 

exam, a finding that was consistent with 

physician studies on the same topic. 26,45,51 

Jellema and colleagues33 reported sensitivities 

of 0.20 to 0.33 from general 

practitioners’ judgments of pain catastrophizing, 

fear-avoidance, and distress 

after a clinical exam in a group of 143 individuals 

with acute low back pain. Waddell 

and Richardson62 reported moderate 

clinician interrater reliability for rating 

overt pain behaviors following multiple 

pilot studies in a group of 120 individuals 

with chronic low back pain. 

While several authors have reported 

on identifying impairments and pain 

behaviors during the clinical exam, 34- 

36,47,60,62,63 none have examined a physical 

therapist’s ability to identify elevated 

fear-avoidance using direct observation 

of the patient’s clinical presentation. 

The primary purpose of this study was 

to evaluate the accuracy with which 

physical therapists identify patient selfreported 

fear-avoidance beliefs using direct 

observation during a clinical exam. 

The study design permitted comparison 

of physical therapists’ judgments of perceived 

patient fear-avoidance beliefs with 

commonly used measures, including the 

FABQ physical activity scale (FABQ-PA), 

FABQ work scale (FABQ-W), Tampa 

Scale of Kinesiophobia 11-item (TSK- 

11), Pain Catastrophizing Scale (PCS), 

and clinical measures of disability using 

the modified Oswestry Disability Questionnaire 

(ODQ), and pain intensity assessed 

using a numeric pain rating scale 

(NPRS). We also investigated physical 

therapist clinical reasoning by recording 

2 therapist-selected influences on 

their perceived patient fear-avoidance 

ratings. A secondary purpose was to investigate 

the concurrent validity of an 

item-driven approach to identification. 

A 2-item questionnaire on fear of physical 

activity and harm was compared to 

established measures of fear-avoidance, 

pain catastrophizing, disability, and 

pain intensity. Responses to the 2-item 

questionnaire were also compared with 

predetermined cut-off values of elevated 

FABQ-PA, FABQ-W, and ODQ scores, to 

assess the potential value of each question 

as a screening tool. 

MetHodS 

a 

ll patients were referred to 

physical therapy departments at 

3 different outpatient clinics in 

Florida, Arizona, and Minnesota. Eligible 

patients were individuals between 

18 and 65 years of age with low back 

pain. Patients were excluded if they had 

a history of lumbar surgery, spinal malignancy, 

spinal infection, cauda equina 

syndrome, ongoing pregnancy, or an inability 

to read and understand English. 

Patients referred to physical therapy 

were contacted by phone or in person by 

the primary investigator at each site to 

review inclusion and exclusion criteria. 

This study was approved by The Institutional 

Review Board at Mayo Clinic, MN 

and the University of Maryland, MD, and 

all participating patients completed an 

approved informed consent form. 

Physical therapists with at least 2 years 

experience working with patients with low 

back pain were recruited for participation 

in the study. Initial therapist interest in 

participating was sought by each site primary 

investigator. All participating therapists 

fulfilled Institutional Review Board 

competency requirements for working 

with patients. Each participating therapist 

completed personal demographic 

information, including years of practice, 

years of practice treating patients with low 

back pain, specialty certification, familiarity 

with the FABQ, duration of prior use 

of the FABQ, personal history of low back 

pain, and confidence rating (0-10) with 

the ability to identify patient fear-avoidance. 

Therapists also completed a selfrated 

FABQ, which is a modified version 

of the FABQ, to assess the treating therapist’s 

own fear-avoidance beliefs about 

low back pain. 46 Therapists attended a 

30-minute education session to review 

the purposes of the study, the concept of 

fear-avoidance, and the requirements for 

enrolling patients. Consecutive patients 

meeting inclusion criteria and agreeing to 

participate in the study were scheduled on 

therapist’s lists until 10 patients had been 

evaluated by each therapist. 

journal of orthopaedic & sports physical therapy | volume 40 | number 12 | december 2010 | 775

Patients were asked to complete a 

standard physical therapy intake form, 

the FABQ, the TSK-11, the PCS, the ODQ, 

and 2 dichotomous questions on fear of 

physical activity and harm, including 

(1) “Are you afraid physical activity will 

cause an increase in your low back pain?” 

and (2) “Are you afraid that moving your 

back will be harmful to you?” The intent 

of asking these 2 questions was to determine 

if there was a simple question that 

could accurately predict elevated fearavoidance 

beliefs, which could be used 

as a screening tool clinically to decrease 

respondent and examiner burden. Wording 

for question 1 was developed from the 

FABQ-PA, which asks questions related 

to fear of physical activity. Wording for 

question 2 was developed from the TSK- 

11, which asks questions related to fear of 

injury and harm. Feedback on question 

wording was sought from 2 therapists 

with experience using the FABQ, and final 

selection of the 2 questions was made 

by the primary author. 

Patients completed all forms prior to 

the therapist evaluation. The order of 

completion of the questionnaires was 

prerandomized for each patient to reduce 

the potential for order bias. Typically, 

patients required 15 to 25 minutes to 

complete the study questions. Once completed, 

all questionnaires were placed 

in a coded envelope by the primary site 

investigator and the treating therapist 

was blinded to patient responses. Treating 

therapists were allowed to use the 

patient-completed standard intake form 

during the evaluation but were blinded 

from the remainder of the questionnaires. 

Therapists completed a standard 

physical therapy evaluation using therapist-selected 

physical exam tests and 

measures. Therapists were specifically 

instructed not to ask patients how fearavoidant 

they were or any question similar 

to it. Following the evaluation, the 

therapist completed a 0-to-10 perceived 

rating of the patient’s level of fear-avoidance 

(0, no fear-avoidance; 10, very high 

fear-avoidance), and selected 2 specific 

factors from a list of 14 choices of why 


they rated the patient with this level of 

fear-avoidance. Therapists were allowed 

to write in up to 2 factors, if not included 

on the list, that guided their clinical reasoning. 

A cut-off score of greater than 

5 was selected to designate elevated 

0-to-10 therapist-perceived patient fearavoidance 

ratings in our study, based on a 

median split of the 0-to-10 scale. 

To achieve greater than 80% power to 

reject the null hypothesis that therapist 

ratings of actual fear-avoidance would 

have a better than chance association, it 

was determined a priori that 70 patients 

would be needed if 40% of the patients 

studied had elevated FABQ scores. 28 

Eighty patients were included in the 

study to provide additional power. At the 

end of the therapist evaluation, the intake 

form, questionnaires, and the therapist 

0-to-10 ratings of patient fear-avoidance 

were placed in a coded envelope and all 

forms were returned to the primary investigator. 

The treating therapists remained 

blinded to gathered patient responses 

and were not given feedback on their rating 

accuracy during the study. At the beginning 

and end of the study, therapists 

were asked a 0-to-10 confidence rating on 

their perceived ability to identify patient 

fear-avoidance beliefs (0, not confident; 

10, very confident). 

Interrater reliability of the physical 

therapist rating of patient fear-avoidance 

beliefs was assessed concurrently during 

data collection on 10 patients. This was 

accomplished by having 1 therapist perform 

a videotaped evaluation of 10 consecutive 

patients and rate their perceived 

patient level of fear-avoidance. Two 

other physical therapists then separately 

viewed the video tape and completed 

their own ratings of perceived patient 

fear-avoidance. Videotape has been used 

in other studies to assess reliability. Fritz 

et al 17 used videotape to determine the interrater 

reliability of therapist assessment 

of the centralization phenomenon in patients 

with low back pain. Each patient 

included in the reliability portion of the 

study gave informed consent to allow the 

therapy session to be videotaped. 


Measures 

Fear-Avoidance Beliefs The FABQ, used 

to measure fear-avoidance, is a 16-item 

spine-specific questionnaire consisting 

of physical activity and work subscales. 

Responders rate their beliefs about work 

and activity from 0 to 6. Not all items are 

used in scoring. The FABQ-PA is scored 

using questions 2, 3, 4, and 5, with a possible 

total of 24. The FABQ-W is scored 

using questions 6, 7, 9, 10, 11, 12, and 

15, with a possible total of 42. 61 Higher 

scores indicate higher levels of fearavoidance. 

In individuals with chronic 

low back pain, internal consistency has 

been reported to have an alpha of .52 to 

.77 for the FABQ-PA and .84 to .92 for the 

FABQ-W. 13,61 Scores on the FABQ have 

been associated with pain, catastrophizing, 

physical impairment, and disability 

in patients with low back pain. 24 

No universally accepted cut-off scores 

for the FABQ exist. 7,18,22,23 For the FABQ- 

W, George et al 22 reported a 2.67 positive 

likelihood ratio for predicting 6-month 

improvement in disability, with a FABQ- 

W score greater than 25 in a cohort of 

individuals with nonoccupational acute 

and chronic low back pain. We selected 

cut-off scores of greater than 25 FABQ- 

W in our study to classify elevated fearavoidance 

beliefs for work, based on a 

cut-off score that has been used previously 

and is associated with disability 

from low back pain. 22 Burton et al 7 used a 

FABQ-PA cut-off score of greater than 14 

to designate elevated fear-avoidance for 

physical activity, based on a median split. 

We selected a cut-off score of greater than 

15 for the FABQ-PA to classify elevated 

fear-avoidance beliefs for physical activity 

in our study, a slightly greater than 

median split value that has been used in 

other randomized controlled trials. 7,21,25 

While use of a median split is a less than 

ideal method to determine a FABQ-PA 

cut-off, it is likely the best available method 

until other studies present empirically 

derived cut-off scores. 

Fear of Movement and Injury The TSK 

is a common scale used to measure fear 

of movement and injury. 54 A modified 11-

item TSK has shown similar psychometric 

properties to the original version. 64 

Items are scored from 1 to 4, where 1 

is “strongly disagree” and 4 is “strongly 

agree.” A total of 44 points is possible, 

with higher scores indicating higher 

levels of kinesiophobia. The TSK-11 assesses 

fear of harm or injury with movement 

and activity avoidance that can be 

used with patients who have multiple 

areas of pain, whereas the FABQ asks 

disease-specific questions related to fear 

of physical activity and work in individuals, 

specifically, with back pain. Internal 

consistency of the TSK was an alpha of 

.68 to .80, when used with individuals 

with chronic low back pain. 13,58 Spearman 

correlations between the TSK and the 

FABQ scales were reported to vary from 

r = 0.55 to 0.76 (P.001) in individuals 

with chronic low back pain and r = 0.33 

to 0.59 (P = .01) in individuals with acute 

low back pain. 13,54 

Pain Catastrophizing Sullivan et al 35 developed 

the PCS, a 13-item self-report 

questionnaire used to quantify patient 

pain catastrophizing. Items on the PCS 

are rated on a 5-point scale, and the 

questionnaire can be subdivided into 

3 components of rumination, magnification, 

and helplessness. The PCS has 

demonstrated good concurrent validity 

with anxiety symptoms, and acceptable 

reliability and internal consistency. 44,52,57 

The PCS has been shown to correlate 

with multiple psychosocial measures, including 

fear-avoidance and depression. 24 

Disability The modified ODQ was used 

to assess patient disability. The ODQ includes 

constructs of pain and functional 

limitations performing common activities 

of daily living. The ODQ is a 10-item 

questionnaire, scored from 0 to 5, that 

has been shown to have good test-retest 

reliability and face and content validity 

for disability in patients with low back 

pain. 16 Scores are doubled to achieve a 

disability rating out of 100 points possible 

and higher scores indicate more disability. 

A cut-off score of greater or equal 

to 30 was selected in our study to indicate 

elevated disability, based on values used 

in other studies, and a score that represents 

a moderate level of disability. 10 

Pain Intensity Patients were asked to rate 

their worst, best, and current level of pain 

in the previous 24 hours on a 0-to-10 (0, 

no pain; 10, maximal pain) numeric pain 

rating scale. These 3 pain ratings were averaged 

to create an average numeric pain 

rating (NPRS). Average 24-hour pain ratings 

have been shown to be responsive to 

changes in individuals with acute low 

back pain and correlate with changes in 

global ratings of change. 10 

Statistical analysis 

SPSS Version 16.0 (SPSS Inc, Chicago, 

IL) and Microsoft Excel 2003 were used 

for the majority of data analysis. Intraclass 

correlation coefficient (ICC 2,1 ) values 

for interrater reliability of therapist 

ratings were calculated using SAS Version 

9.1 (SAS, Cary, NC). 

Therapist Perception of Fear-Avoidance 

Compared to Established Measures 

Spearman correlation was used to 

determine correlations among therapist 

perception of fear-avoidance and measures 

of pain-related fear (FABQ-PA, 

FABQ-W, and TSK-11), pain catastrophizing 

(PCS), disability (ODQ), and pain 

intensity (NPRS). Frequency counts for 

therapist reasons for making fear-avoidance 

perception ratings were reported 

descriptively to supplement these analyses. 

Likelihood ratios with 95% confidence 

intervals were calculated using 

2-by-2 contingency tables for the most 

frequent therapist-selected responses to 

determine relationships with therapistselected 

reasoning and elevated FABQ- 

PA and ODQ scores. 

Validity of 2-Item Screening Questions 

Independent t tests were used to 

determine differences in measures of 

pain-related fear (FABQ-PA, FABQ- 

W, and TSK-11), pain catastrophizing 

(PCS), and therapist 0-to-10 perception 

of patient fear-avoidance, based on the 

response to the 2-item fear of activity 

and fear of harm screening questions. 

Independent t tests were also used to determine 

differences in clinical measures 

for disability (ODQ) and pain intensity 

(NPRS). Then the potential of the screening 

items was further assessed for ability 

to identify those with elevated FABQ-PA, 

FABQ-W, and ODQ scores with 2-by-2 

contingency tables and chi-square analyses. 

Two-by-two contingency tables were 

used to generate sensitivities, specificities, 

and resultant likelihood ratios with 

95% confidence intervals for the 2 questions 

on fear of physical activity and harm 

to predict elevated FABQ-PA and FABQ- 

W scores. Shifts in pretest to posttest 

probability of elevated FABQ-PA scores 

based on responses to the 2-item screening 

questions were generated specific to 

the study sample using Bayes theorem. 4 

reSultS 

one hundred two patients with 

low back pain, between the ages of 

18 and 65 years, referred to the 3 

physical therapy clinics between April 

2008 and October 2008, were contacted, 

and 80 patients were enrolled in the 

study. Reasons for not participating included 

patients not interested (n = 8), 

rescheduled/no show (n = 6), symptoms 

resolved (n = 1), sought care elsewhere (n 

= 1), and not meeting inclusion criteria 

once contacted due to prior lumbar surgery 

(n = 3), thoracic spine pain not low 

back pain (n = 2), and lumbar infection 

(n = 1). Baseline scores for enrolled patient 

demographic and self-report data 

are found in table 1. Baseline therapist 

demographic and self-report scores are 

found in table 2. Interrater reliability calculations 

of 2 therapist’s blinded 0-to-10 

ratings of perceived patient fear-avoidance 

from 10 videotaped patients compared 

with the initial therapist 0-to-10 

ratings yielded ICC 2,1 = 0.663 (95% CI: 

0.424, 0.880). 

therapist Perception of Fear-avoidance 

compared to established Measures 

Average 0-to-10 self-reported therapist 

confidence in their ratings of patient-perceived 

fear-avoidance was 5.4 prestudy 

and 6.3 poststudy (table 2). Spearman 


correlations of therapist 0-to-10 ratings 

of perceived patient fear-avoidance with 

self-reported questionnaires are found in 

table 3. Therapist 0-to-10 ratings showed 


table 1 Patient Demographic and Self-Report Measures 

Patient variables values* 

Age (y) 46.6 11.5 

Gender (n female patients) 46/80 (57.5%) 

Duration of pain (wk) 185.7 354.4 

Low back pain 3 mo (n) 53/80 (66.3%) 

Employment (n full-time employed) 56/78 (71.8%) 

Workman's compensation 7/80 (8.8%) 

Average 24-h numeric pain rating scale (0-10 rating) 3.7 1.9 

Elevated pain, numeric pain rating scale 5 21/80 (26.3%) 

Self-reported liking to exercise 56/78 (71.8%) 

Fear-Avoidance Beliefs Questionnaire physical activity scale (score range, 0-24) 12.7 6.0 (0-24) 

Elevated Fear-Avoidance Beliefs Questionnaire physical activity scale (15) 30/80 (37.5%) 

Fear-Avoidance Beliefs Questionnaire work scale (0-42) 12.0 10.5 (0-39) 

Elevated Fear-Avoidance Beliefs Questionnaire work scale (25) 8/80 (10.0%) 

Yes to "Are you afraid physical activity will cause an increase in your low back pain?" 44/80 (53.0%) 

Yes to "Are you afraid that moving your back will be harmful to you?" 21/80 (25.3%) 

Tampa Scale of Kinesiophobia 11-item (11-44) 24.4 5.9 (16-42) 

Pain Catastrophizing Scale (0-52) 13.9 10.1 (0-50) 

Modified Oswestry Disability Questionnaire (0-100) 30.2 13.6 (8-70) 

Elevated disability (ODQ30) 37/80 (46.3%) 

Abbreviation: ODQ, Modified Oswestry Disability Questionnaire. 

* Values are reported as mean SD (range), where applicable, or n/total sample (percentage). 

table 2 

Therapist Demographic 

and Self-Report Measures 

Measures values* 

Years as a physical therapist 13.9 7.7 

Years working with patients with low back pain 13.9 7.7 

Familiar with the Fear-Avoidance Beliefs Questionnaire 6/8 (75.0%) 

Years using the Fear-Avoidance Beliefs Questionnaire 0.9 1.1 

An entry-level doctoral degree or higher 2/8 (25.0%) 

Board specialty certification 3/8 (37.5%) 

Have acute low back pain 4/8 (50.0%) 

Have chronic low back pain 1/8 (12.5%) 

Have recurrent low back pain 2/8 (25.0%) 

Confidence rating in self-ability to identify fear-avoidance beliefs prestudy (0-10 rating) 5.4 1.8 

Confidence rating in self-ability to identify fear-avoidance beliefs poststudy (0-10 rating) 6.3 1.4 

Self-rated Fear-Avoidance Beliefs Questionnaire physical activity scale 8.3 6.1 

Self-rated Fear-Avoidance Beliefs Questionnaire work scale 5.3 6.3 

Elevated self-rated Fear-Avoidance Beliefs Questionnaire scores 

* Values are reported as mean SD, or n/total sample (percentage). 

0/8 (0.0%) 

statistically significant association with 

the ODQ and PCS, and approached significance 

with the NPRS (P = .056). No 

statistically significant correlation was 


found between therapist 0-to-10 perceived 

patient fear-avoidance ratings and 

the FABQ-PA, FABQ-W, or TSK-11. 

Therapist-reported reasoning for 

rating perceived patient fear-avoidance 

is shown in table 4. Therapists selected 

factors that favored lower fear-avoidance 

in 41 patients (51.3%), higher fear-avoidance 

in 28 patients (35%), and both low 

and high fear-avoidance in 11 patients 

(13.8%). Therapists rated patients to have 

elevated fear-avoidance 12.5% of the time 

(greater than 5 on 0-to-10 scale), while 

actual elevated (greater than 15) FABQ- 

PA scores were present in 37.5% of the 

patients. The most common reported influence 

on therapist ratings was a patient 

responding liking to exercise (31.3%), 

followed by patient reported lower pain 

rating (20.0%). Self-reported liking to 

exercise was not correlated with elevated 

FABQ-PA scores (positive likelihood ratio 

[LR], 1.41; 95% CI: 0.70, 2.84; negative 

LR, 0.87; 95% CI: 0.64, 1.18) or elevated 

ODQ scores (positive LR, 1.17; 95% CI: 

0.58, 2.37; negative LR, 0.94; 95% CI: 

0.71, 1.25). 

validity of 2-item Screening Questions 

Independent t tests of the afraid of physical 

activity question showed significant 

mean differences for all measures of interest, 

except for the NPRS (table 5). In 

all instances, higher fear, catastrophizing, 

and disability scores were associated with 

a positive response to the physical activity 

screening question. Independent t tests 

of the afraid of harm question showed 

significant differences for the FABQ-PA 

only (table 5). Higher FABQ-PA scores 

were associated with a positive response 

to the harm screening question. Further 

investigation of the screening potential 

of these questions by chi-square analysis 

indicated that both items identified 

elevated FABQ-PA scores better than 

chance (table 6), but not elevated FABQ- 

W or ODQ scores. 

Follow-up analysis of the fear of physical 

activity question generated a negative 

LR of 0.28 (95% CI: 0.12, 0.63) and a 

positive LR of 2.11 (95% CI: 1.43, 3.09)

table 3 

for identifying elevated (greater than 

15) FABQ-PA scores. The fear of harm 

question generated a negative LR of 0.62 

(95% CI: 0.44, 0.89) and a positive LR 

of 3.2 (95% CI: 1.5, 7.0) for identifying 

elevated (greater than 15) FABQ-PA 

scores. Using a 37.5% pretest probability 

prevalence of elevated FABQ-PA (generated 

from our cohort and not necessarily 

representative of other populations), a 

Association Between Therapist 0-to-10 Ratings 

and Self-Reported Patient Questionnaires* 

variable FabQ-W nPrS odQ PcS tSk-11 therapist 0-10 

FABQ-PA 0.423 

Abbreviations: FABQ-PA, Fear-Avoidance Beliefs Questionnaire physical activity scale; FABQ-W, 

Fear-Avoidance Beliefs Questionnaire work scale; NPRS, numeric pain rating scale; ODQ, Modified 

Oswestry Disability Questionnaire; PCS, Pain Catastrophizing Scale; TSK-11, Tampa Scale of Kinesiophobia 

11-item. 

* Spearman rank correlation coefficients. n = 80, except for PCS, where n = 79. 

† Correlation is significant at the 0.01 level (2-tailed). 

‡ Correlation is significant at the 0.05 level (2-tailed). 

† 0.366 † 0.491 † 0.258 ‡ 0.550 † 0.097 

FABQ-W 0.382 † 0.421 † 0.409 † 0.310 † 0.207 

NPRS 0.608 † 0.366 † 0.236 ‡ 0.215 

ODQ 0.356 † 0.230 ‡ 0.383 † 

PCS 0.435 † 0.290 † 

TSK-11 0.056 

table 4 

Frequency of Therapist-Selected Reasoning for 

Rating Perceived Patient Fear-Avoidance Levels* 

reason Frequency 

Patient likes to exercise 25 (31.3%) 

Low pain rating 16 (20.0%) 

No pain behaviors 14 (17.5%) 

Limited lumbar range of motion 

* Values represent frequency (percent) out of 80 possible patients (n = 160). 

† Reasons likely influencing higher therapist-perceived patient fear-avoidance ratings. 

† 11 (13.8%) 

Pain behaviors † 10 (12.5%) 

Muscle guarding † 10 (12.5%) 

Good patient effort 10 (12.5%) 

Slow speed of movement † 9 (11.3%) 

Fast speed of movement 7 (8.8%) 

High pain rating † 6 (7.5%) 

Positive attitude 6 (7.5%) 

Doesn't like to exercise † 5 (6.3%) 

Yellow flags present † 5 (6.3%) 

Facial grimacing † 4 (5.0%) 

No muscle guarding 4 (5.0%) 

Normal lumbar range of motion 4 (5.0%) 

Other reasons 14 (17.6%) 

“no” response to the fear of physical activity 

question (negative LR, 0.28) shifts 

a posttest fear-avoidance probability to 

14.4%. 4 A “yes” response to the fear of 

harm question (positive LR, 3.2) shifts 

a posttest fear-avoidance probability to 

65.8%. 4 Likelihood ratios of the 2-item 

questions for elevated (greater than 25) 

FABQ-W scores generated small shifts in 

posttest elevated FABQ-W probabilities 

(negative LR of 0.84 to 2.27 and a positive 

LR of 0.20 to 1.12). 

diScuSSion 

The primary aim of the present 

study was to determine if physical 

therapists could identify elevated 

patient fear-avoidance beliefs measured 

by the FABQ, TSK-11, or PCS. Therapist 

0-to-10 ratings of perceived patient 

fear-avoidance were not associated with 

patient fear-avoidance as measured by 

FABQ-PA, FABQ-W, and TSK-11, but had 

statistically significant association with 

the PCS. Therapists were moderately 

confident in their ability to identify elevated 

fear-avoidance beliefs. The difficulty 

with identifying elevated self-reported 

fear-avoidance beliefs seen in our study 

is consistent with the reported difficulty 

therapists and physicians have had identifying 

other psychosocial factors. 26,27,45,51 

One explanation of our study findings 

could be that therapists’ judgments consistently 

incorrectly interpreted patient 

fear-avoidance beliefs. 

Therapist-perceived patient fearavoidance 

ratings were fair to moderately 

reliable (ICC 2,1 = 0.663; 95% CI: 0.424, 

0.880) but not associated with self-report 

fear-avoidance questionnaires. This 

would suggest that the behavioral signs of 

fear-avoidance may differ from what is assessed 

on self-report questionnaires like 

the FABQ and TSK-11. The disconnect 

reported in our study between observable 

patient fear-avoidant behaviors and 

self-reported fear-avoidance measures 

could bring into question the concurrent 

validity of the FABQ and TSK-11 scales 

with behavioral aspects of fear-avoidance. 

It may be that clinician judgments 

of perceived patient fear-avoidance, in 

our study, considered different facets of 

the complex construct of fear-avoidance 

that were not captured by the FABQ and 

TSK-11, such as patient affect and behavior 

during clinical examination. 14 

Another interpretation of these results 

is that therapist 0-to-10 ratings of 

fear-avoidance were influenced by differ- 


table 5 

ent but related constructs, such as pain 

catastrophizing or disability. In our study, 

therapist 0-to-10 ratings had small but 

statistically significant correlation with 

pain catastrophizing, another major 

component of the fear-avoidance model. 

Pain catastrophizing is comprised of rumination, 

magnification, and helplessness 

cognitions and has been associated 

with heightened pain responses in both 

clinical and experimental studies. 53 It is 

plausible that heightened pain responses 

associated with pain catastrophizing 

might have been more readily apparent 

to a clinician during examination in 


Comparison of Group Mean Responses 

to 2-Item Screening Questions With 

Self-Reported Patient Questionnaires* 

yes to afraid of no to afraid of 

Physical activity Physical activity yes to afraid of no to afraid of 

variable (n = 44) (n = 36) P value 

Abbreviations: FABQ-PA, Fear-Avoidance Beliefs Questionnaire physical activity scale; FABQ-W, 

Fear-Avoidance Beliefs Questionnaire work scale; NPRS, numeric pain rating scale; ODQ, Modified 

Oswestry Disability Questionnaire; PCS, Pain Catastrophizing Scale; TSK-11, Tampa Scale of Kinesiophobia 

11-item. 

* Values represent mean SD, except where indicated otherwise. 

† 2-tailed independent t test. 

† Harm (n = 21) Harm (n = 59) P value † 

FABQ-PA 15.8 4.3 8.9 5.7 .01 15.5 6.9 11.7 5.3 .01 

FABQ-W 15.5 9.7 7.9 10.0 .01 11.3 10.4 12.4 10.6 .69 

NPRS 4.0 1.9 3.4 1.9 .14 4.1 2.6 3.6 1.5 .26 

ODQ 34.4 14.0 25.1 11.4 .01 33.7 16.8 28.9 12.2 .17 

PCS 16.7 11.0 11.0 8.0 .01 17.5 13.5 12.9 8.4 .07 

TSK-11 26.0 5.1 22.5 6.4 .01 26.2 5.3 23.8 6.0 .11 

table 6 

Chi-Square Analysis of 2-Item 

Screening Questions With Elevated 

FABQ-PA, FABQ-W, and ODQ Scores 

yes to afraid of no to afraid of yes to afraid no to afraid 

variable Physical activity Physical activity P value of Harm of Harm P value 

FABQ-PA score 15 .01 .01 

Yes 25 (56.8%) 5 (13.9%) 14 (66.7%) 16 (27.1%) 

No 19 (43.2%) 31 (86.1%) 7 (33.3%) 43 (72.9%) 

FABQ-W score 25 .65 .35 

Yes 5 (11.4%) 3 (8.3%) 1 (4.8%) 7 (11.9%) 

No 39 (88.6%) 33 (91.7%) 20 (95.2%) 52 (88.1%) 

ODQ score 30 .23 .88 

Yes 23 (52.3%) 14 (38.9%) 10 (47.6%) 27 (45.8%) 

No 21 (47.7%) 22 (61.1%) 11 (52.4%) 32 (54.2%) 

Abbreviations: FABQ-PA, Fear-Avoidance Beliefs Questionnaire physical activity scale; FABQ-W, Fear- 

Avoidance Beliefs Questionnaire work scale; ODQ, Modified Oswestry Disability Questionnaire. 

comparison to fear-avoidance behaviors, 

though therapists did not specifically rate 

pain catastrophizing in our study. 

Our study found that therapist 0-to-10 

ratings had the strongest association with 

disability scores among all self-reported 

questionnaires. One reason therapist ratings 

were associated with elevated ODQ 

scores could be that the ODQ addresses 

functional limitations that can be observed 

during the physical exam, including 

walking, sitting, and standing. 16 As 

part of the physical examination process, 

therapists are trained to use clinical exam 

findings to form a differential diagnosis 


and prognosis. 1 Perhaps therapists were 

better able to identify elevated disability 

in this study because experienced physical 

therapists are skilled in identifying 

functional limitations and pain quantified 

by the ODQ. These skills may have 

confounded their ability to make isolated 

determinations about fear-avoidance. 

This finding may have implications for 

therapists’ ability to make perceived 

judgments about psychosocial prognoses 

in patients with low back pain. 

We attempted to understand therapist-driven 

identification of patient 

fear-avoidance by recording 2 therapistselected 

influences on their ratings of 

perceived patient fear-avoidance. The 

most common influence on therapist ratings 

was patient self-reporting liking to 

exercise (31.3%), and patient self-reported 

liking to exercise was high in the study 

(71.8%). However, self-reported liking to 

exercise was not associated with FABQ 

scores in our study and might have been 

a confounder to accurate fear-avoidance 

ratings. Therapists listed low pain ratings 

as an influence 20% of the time, but 

therapists listing low pain rating as an influence 

correctly identified only 50% of 

the patients with low FABQ-PA scores. 

Therapist underrating perceived patient 

fear-avoidance in comparison to actual 

FABQ-PA scores was common in our 

study. Examiner underrating psychosocial 

variables has been reported in other 

studies, particularly among patients with 

elevated pain. 50,65 Underrating actual 

scores in our study may be due to the 

overly positive view physical therapists 

have about their patients or a variable 

relationship between the expressional 

components of fear and self-reported 

fear-avoidance beliefs. 40 

Another aim of the present study was 

the investigation of dichotomous 2-item 

screening question association with elevated 

fear-avoidance, pain catastrophizing, 

and disability. The fear of physical 

activity question was broadly associated 

with FABQ-PA, FABQ-W, TSK-11, 

PCS, and ODQ scores, while the fear of 

harm question was associated only with

FABQ-PA scores. Because the fear of 

harm question showed differences only 

with the FABQ-PA, and was able to identify 

elevated FABQ-PA scores better than 

chance, it may have greater value as a 

specific screening tool for elevated FABQ- 

PA scores. Follow-up chi-square analysis 

showed that both 2-item questions were 

associated with elevated (greater than 15) 

FABQ-PA scores but not elevated FABQ- 

W or ODQ scores. 

Use of item-driven identification of 

fear-avoidance beliefs has been utilized 

in the literature and may have direct 

clinical implications. The identification 

of a single question to identify patients 

at risk for elevated fear-avoidance scores 

may have value for increasing exam efficiency 

and decreasing patient and examiner 

burden. Hart et al 29 reported that the 

use of a single FABQ-PA item, “I should 

not do physical activities which (might) 

make my pain worse,” with a cut-off score 

of 4, showed excellent specificity (0.98) 

and good sensitivity (0.82), highlighting 

another possible 1-item screen of fearavoidance 

beliefs that was developed with 

item response theory. 

limitations and Future Studies 

There are several potential limitations 

to our study. Therapists in this study 

had considerable experience working 

with patients with low back pain but had 

limited experience using the FABQ. Perhaps 

more experience using the FABQ 

would have improved therapist accuracy 

in rating fear-avoidance, although 

it should be noted that clinician experience 

wasn’t a significant factor in other 

studies examining the screening accuracy 

of psychosocial factors. 27,33 Several 

physical exam factors have been shown 

to correlate with elevated FABQ scores, 

and our study did not assess therapists’ 

awareness of the physical examination 

factors. 2,3,12,13,20,23,48,55,58 No specific training 

was given in this study for identifying 

factors that correlate with elevated 

fear-avoidance, so that unbiased therapist 

judgments were assessed, and small 

improvements have been seen following 

clinician training in other studies. 33,50 

Perhaps training therapists in how to 

identify factors that correlate with elevated 

fear-avoidance on exam and allowing 

therapists to ask specific follow-up 

questions about fear-avoidance would 

improve therapist accuracy. 

The sample size of 80 was chosen a 

priori on the basis of the number needed 

to have greater than 80% power to reject 

the null hypothesis, based on previously 

reported frequencies of elevated fearavoidance. 

A larger sample size would 

have helped to decrease the potential 

of a type II error. Although the ranges 

of self-reported questionnaire scores in 

our study were broad, our modest sample 

size might have captured a group of 

individuals with narrow psychosocial 

profiles, which could have altered therapist 

rating accuracy. Our study sample 

was comprised of a small number of patients 

receiving workers compensation 

(8.8%), and only 10% of the patients 

had elevated FABQ-W scores. Because 

therapist 0-to-10 ratings weakly correlated 

with the FABQ-W, it may be that 

therapist judgments of perceived patient 

fear-avoidance would be different in a 

population with a higher prevalence of 

patients receiving workers compensation. 

The shift in probabilities calculated 

in our study, based on responses to the 

2-item screening questions, was highly 

sample dependent and may not be representative 

of the prevalence of elevated 

fear-avoidance in a larger cohort of individuals 

with low back pain. It also cannot 

be assumed that therapist judgments of 

perceived patient fear-avoidance generalize 

to other professions or healthcare 

populations. 

The primary purpose of our study 

was to assess therapist rating accuracy 

of patient fear-avoidance after an initial 

evaluation; therefore, a patient followup 

was not included. Because therapist 

fear-avoidance ratings correlated with 

elevated baseline disability and pain 

catastrophizing, it may be of interest to 

further evaluate if perceived therapist 

0-to-10 ratings are able to predict long- 

term disability outcomes or changes in 

pain catastrophizing. Further evaluation 

of the psychometric properties of the 2 

screening questions in a larger population 

is needed to validate the utility of 

a dichotomous fear-avoidance screening 

question. Finally, it may be of value 

to develop a standard clinical tool that 

captures the behavioral aspects of fearavoidance 

behaviors and beliefs during 

routine clinical examination, which may 

be different from the current construct 

of fear-avoidance captured by the FABQ 

and TSK-11. 

concluSion 

identifying psychosocial factors 

is potentially valuable for clinicians 

working with patients with low back 

pain. Therapist 0-to-10 ratings of perceived 

patient fear-avoidance had moderate 

reliability but did not correlate with 

FABQ or TSK-11 scores. 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 related factors. 

The fear of physical activity question 

had significant associations with 

all fear-avoidance, pain catastrophizing, 

and disability measures and showed potential 

to identify lower FABQ-PA scores. 

The fear of harm question had significant 

association specific only to the FABQ-PA 

and showed potential to identify elevated 

FABQ-PA scores. t 

key PointS 

FindinGS: Therapist ratings of perceived 

patient fear-avoidance were not associated 

with fear-avoidance measures, 

but were associated with pain catastrophizing 

and disability scores. Two 

dichotomous questions related to physical 

activity and harm showed potential 

for identifying elevated fear-avoidance 

beliefs. 

iMPlicationS: Therapists should not rely 

solely on their own judgments to identify 

self-reported fear-avoidance beliefs. 


caution: Clinician accuracy for identifying 

self-reported patient elevated 

fear-avoidance beliefs might show 

differences when studied in a patient 

population with different demographic 

factors, with training provided ahead 

of time, or by including therapists that 

have more experience using the FABQ. 

Acknowledgments: Special thanks to Roy 

Bechtel, PT, PhD for guidance with this 

research project, and to the physical therapy 

and support staff at Mayo Clinic Rochester, 

Arizona and Florida for assistance with 

this project. 

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