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Fear-avoidance-based physical therapy for acute lower back pain

Three Part Question

In [acute low back pain patients presenting with high fear-avoidance of physical activity] is [fear-avoidance-based physical therapy better than standard care physical therapy] in [reducing pain, fear-avoidance beliefs of physical activity and disability]

Clinical Scenario

A 39 year old man referred to the PT clinic with a 3 weeks history of low back pain. There is no history of back pain or work-related back injury. At the L4-L5 level, there is herniated nucleus pulposus without nerve root compromise as shown in the MRI images. He has limitation of lumbar spinal mobility without red flags. He is normally fit and well. He is extremely afraid that any physical activity might damage his back. You wonder how to plan a rehabilitation program that will help to reduce his fear along with pain and risk of disability.

Search Strategy

Medline 1950 to March Week 1 2008 (OVID)
PEDro (Physiotherapy Evidence Database)
Cochrane Library Issue 1, 2008
Medline 1950 to March Week 1 2008 (OVID):
[fear-avoidance] AND [exp Back Pain/ or exp Low Back Pain/ or Acute low back] AND [exp Exercise Therapy/ or exp Physical Therapy Modalities/ or Physical]
(fear-avoidance beliefs):ti,ab,kw
Cochrane Library Issue 1, 2008
(fear-avoidance beliefs):ti,ab,kw

Search Outcome

69 papers were found, of which 1 was relevant to the three part question.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
George et. al.,
66 patients with low back pain of less than 8 weeks' duration (aged 18 to 55 years). Randomised to either standard care physical therapy (n=32) (G1) or fear-avoidance–based physical therapy (n=34) (G2). Total treatment time was limited to 1 hour per patient per therapy session for 4 weeks. Both groups were comparable in all measured parameters at baseline. Follow-up were conducted at 4 weeks and 6 months after treatment.PRCTPain Intensity (mean). (0-10)At 4 weeks: 2.6 for G1 vs. 1.9 for G2. Mean Difference = 0.7 (95% CI -0.5 to1.5) P = 0.288. At 6 months: 1.5 for G1 vs. 1.7 for G2. Mean Difference = -0.1 (95% CI -1.2 to 0.9) P = 0.779.Blinding of the patients and clinicians were not possible in this trial. No adequate follow-up.
Fear-Avoidance Beliefs Questionnaire about physical activity (FABQ-PA) (mean). (0-24)At 4 weeks: 14.9 for G1 vs. 10.7 for G2. Mean Difference = 4.2 (95% CI 1.3 to 7.1) P = 0.006. At 6 months: 13.5 for G1 vs. 10.1 for G2. Mean Difference = 3.4 (95% CI 0.2 to 6.6) P = 0.037.
Oswestry Disability Questionnaire (ODQ) (mean). (0-100)At 4 weeks: 21.5 for G1 vs. 17.7 for G2. Mean Difference = 3.8 (95% CI -5.5 to 13.1) P = 0.422. At 6 months: 15.5 for G1 vs. 11.9 for G2. Mean Difference = 3.6 (95% CI -3.5 to 10.8) P = 0.317.


High fear-avoidance beliefs about physical activity can be determined by scoring 15 or more on the fear-avoidance beliefs questionnaire about physical activity (FABQ-PA). The fear-avoidance-based physical therapy intervention is including a graded exercise program combined with fear-avoidance education that involves the Back Book educational pamphlet. According to this well designed trail, a significant decrease in fear-avoidance beliefs about physical activity was observed in patients receiving the fear avoidance–based physical therapy at 4 weeks and 6 months, respectively. However, this trial has short follow up periods. Future RCTs should attempt to determine outcome over a longer period of time.

Clinical Bottom Line

In adult patients with acute low back pain and elevated fear-avoidance beliefs of physical activities the fear-avoidance-based physical therapy intervention is significantly better in reducing fear-avoidance beliefs only when compared to the standard care physical therapy.


  1. George SZ, Fritz JM, Bialosky JE, Donald DA The Effect of a Fear-Avoidance-Based Physical Therapy Intervention for Patients With Acute Low Back Pain: Results of a Randomized Clinical Trial. Spine 2003;2551-2560