Fear and Fear Avoidance – Research Update -May 2014

I though it about time to provide an update regarding some recent articles/publications relating to the topic of Fear and Fear Avoidance.

As seen in an earlier post, Fear is an important psychosocial factor that we need to be aware of when assessing and treating patients. The new research continues to provide support for this.

Wertli et al (2014) conducted a systematic review investigating “The Role of Fear Avoidance Beliefs as a Prognostic Factor for Outcome in Patients with Non-Specific Low Back Pain”. The authors included 21 studies that assessed Fear Avoidance beliefs (utilising the Fear Avoidance Beliefs Questionnaire and/or the Tampa Scale of Kinesiophobia) in patients with non-specific low back pain (LBP). Conclusions suggested that:

Fear avoidance beliefs are prognostic for poor outcome in sub-acute LBP and thus early treatment, including interventions to reduce fear avoidance beliefs, may avoid delayed recovery and chronicity.

A recent study by Thibodeau et al (2013) investigating fear of injury in chronic lower back pain patients demonstrated that:

Fear of injury directly predicted pain-related anxiety and indirectly predicted impairment through pain-related anxiety.

Domenech et al (2013) investigated the “Influence of kinesiophobia and catastrophizing on pain and disability in anterior knee pain patients”. The authors conducted a cross-sectional study on 97 patients with chronic anterior knee pain. Results showed that: 

Pain was not able to explain all the variability of disability, and that the findings support the fear avoidance model in the genesis and persistence of pain and disability in anterior knee pain patients.

Finally, Mannion et al (2013) conducted a cross-sectional population based survey to investigate the relationship between low back pain (LBP) beliefs and care-seeking. 2507 patients completed the survey which contained the:

  1. Back Beliefs Questionnaire (BBQ).
  2. Fear-Avoidance Beliefs Questionnaire (FABQ; physical activity and work scales).
  3. Questions about sociodemographics, LBP characteristics and LBP-related care-seeking in the last month

Results showed that:

The odds of seeking care are higher in fear-avoidant individuals, even when controlling for other established predictors.
So the research continues to show the role of fear in the development and persistency of pain states. Fear being something we should be regularly screening for via:
  1. Direct questioning of patients during the subjective and objective examination.
  2. The use of screening tools such as the Tampa Scale for Kinesiophobia and Fear Avoidance Beliefs Questionnaire.

Addressing Fear, when present, would then seem of paramount importance in the treatment of patients. How we as physiotherapists might address it could simply begin with:

  1. Educating them regarding any faulty beliefs they have.
  2. Reducing their pain via manual therapy and/or exercises (reducing the pain might reduce the fear).

Being mindful that if the above is not producing positive outcomes that Clinical Psychology and/or Medical review might be necessary.

Any other thoughts?

Thanks for reading.


Domenech J, Sanchis-Alfonso V, López L, Espejo B. Influence of kinesiophobia and catastrophizing on pain and disability in anterior knee pain patients. Knee Surg Sports Traumatol Arthrosc. 2013 Jul;21(7):1562-8.

Mannion AF, Wieser S, Elfering A. Association Between Beliefs and Care-Seeking Behavior for Low Back Pain. Spine (Phila Pa 1976). 2013 Mar 1. [Epub ahead of print].

Thibodeau MA, Fetzner MG, Carleton RN, Kachur SS, Asmundson GJ. Fear of injury predicts self-reported and behavioral impairment in patients with chronic low back pain. J Pain. 2013 Feb;14(2):172-81. doi: 10.1016/j.jpain.2012.10.014. Epub 2012 Dec 20.

Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. Spine J. 2014 May 1;14(5):816-836.

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Sessional Academic at Curtin University. The views expressed on this blog are his own.

2 Comments on "Fear and Fear Avoidance – Research Update -May 2014"

Trackback | Comments RSS Feed

Post a Comment

%d bloggers like this: