Physical therapist management of a patient with acute low back pain and elevated fear-avoidance beliefs.

Most patients with an acute episode of low back pain (LBP) recover relatively quickly, whereas a smaller percentage eventually have persistent pain or chronic disability. (1,2) Research has consistently confirmed that psychosocial factors, instead of physical impairments, are the best predictors of which patients will develop chronic disability from an acute episode of LBP. (3-6) The Fear-Avoidance Model of Exaggerated Pain Perception (FAMEPP) (7,8) was developed to explain why some individuals' symptoms resolve and the individuals return to prior levels of activity, whereas others have continued symptoms and disability. In this model, fear of pain and the resultant avoidance behavior (fear-avoidance beliefs) are hypothesized to be the most important factors in determining whether a person will experience chronic disability after an episode of acute LBP. (7)

In the FAMEPP, a person's reaction to a painful experience is proposed to fall somewhere along a spectrum ranging from confrontation to avoidance. (7,8) Patients with LBP and lower levels of fear-avoidance beliefs are hypothesized to be "confronters," and those with higher levels of fear-avoidance beliefs are hypothesized to be "avoiders." (7,8) Confrontation is perceived to be an adaptive response to LBP and is hypothesized to be associated with a gradual return to the patient's desired functional level. (7,8) Avoidance is perceived to be a maladaptive response to LBP and is hypothesized to be associated with chronic disability. (7,8) Psychological consequences (eg, exaggerated pain perception) and physical consequences (eg, "disuse syndrome" [decreased spine range of motion, loss of muscle force, and weight gain]) are associated with an avoidance response. (7-10) The underlying assumption of the FAMEPP is that the patient's LBP is not from a serious pathological source (eg, fracture, tumor, infection, or nerve root compression), and therefore all avoidance behavior is viewed as maladaptive.

Longitudinal studies (11) have suggested that elevated fear-avoidance beliefs are a precursor to prolonged disability. (12,13) Klenerman et al, (11) for example, found that initial fear-avoidance beliefs were the best predictor of disability 2 months later in a group of patients with acute LBP seeking treatment from general practitioners. In patients receiving physical therapy for work-related, acute LBP, Fritz et al (12) found that higher fear-avoidance beliefs predicted continued disability and prolonged work absence, even after controlling for initial pain and disability. In a recent review article, Vlaeyen and Linton summarized the implication of these findings: "Pain-related fear and avoidance appears to be an essential feature of the development of a chronic problem for at least some patientS." (14(p329) For this reason, intervention that applies principles of the FAMEPP has been advocated. (12,14,15) One approach follows a 3-step process: (1) screening for patients with elevated fear-avoidance beliefs, (2) educating patients with elevated fear-avoidance beliefs in a specific manner, and (3) prescribing exercise that directly addresses the patient's fear and avoidance behavior. (14)

Numerous authors (12,14,15) have suggested that the Fear-Avoidance Beliefs Questionnaire (FABQ) (15) is an appropriate instrument to identify patients with LBP who have elevated fear-avoidance beliefs and who may be at increased risk for prolonged disability. An FABQ physical activity scale score of greater than 15 has been proposed as an indicator of "high" fear-avoidance beliefs for patients seeking primary care or osteopathic treatment. (16) This score was derived from a median split (ie, first 50% of scores designated as "low," second 50% of scores designated as "high") of FABQ scores, however, and does not provide information on the increased probability of prolonged disability (ie, if an FABQ score is designated "high" by median split technique, it does not necessarily mean there is an increased chance of prolonged disability). Fritz and George (13) studied a group of patients with acute, work-related LBP and demonstrated that FABQ work scale scores greater than 34 were associated with an increased risk of not returning to work (positive likelihood ratio = 3.33, 95% confidence interval = 1.65, 6.77) and work scale scores of less than 29 were associated with a decreased risk of not returning to work (negative likelihood ratio = 0.08, 95% confidence interval = 0.01, 0.54).

Patient education based on a fear-avoidance model encourages confrontation and consists of "unambiguously educating the patient in a way such that the patient views his or her pain as a common condition, rather than as a serious disease that needs careful protection." (14)(p328) Studies (16-18) have focused only on using educational pamphlets to deliver this message and have not described the interaction between the practitioner and the patient. Key principles from one commonly used pamphlet (The Back Book) (19) are outlined in Table 1 and contrasted with principles from a traditional educational pamphlet (Handy Hints). (20) Reduction in fear-avoidance beliefs and negative beliefs about back pain have been observed when fear-avoidance-based pamphlets were used to educate patients in work and clinical settings. (16,18)

Use of graded exercise has been recommended for patients with acute LBP and high levels of fear-avoidance beliefs. (14) Graded exercise prescription is quota driven and focuses on improving the patient's activity tolerance by progressing quota parameters (ie, intensity, duration, or frequency of exercise). (21,22) With graded exercise, the patient's reported symptom intensity does not limit exercise progression, and symptom abatement is not considered the primary intervention goal. (21) Theoretically, this approach complements the FAMEPP because it uses exercise prescription to encourage the patient to be a confronter. Controlled trials have shown that graded exercise is a component of successful management of patients with subacute and chronic LBP. (22-25) According to van Tulder et al, (26) effective exercise prescription for patients with acute LBP has not been documented in the literature. Specifically, randomized trials have demonstrated no consistent effect of spine range of motion, strengthening, stretching, and aerobic exercises for reduction of symptoms or disability. (26) Patients in the randomized trials, however, did not have intervention following treatment-based classification guidelines. (27) In addition, behavioral interventions, such as graded exercise, have not been investigated for effectiveness in patients with acute LBP. Therefore, the dubious findings of the effectiveness of exercise prescription may not be directly applicable to physical therapist management that includes treatment-based classification and graded exercise.

Physical therapist management integrated with fear-avoidance principles has not been previously described for a patient with acute LBP. We propose that physical therapists should be able to identify patients with elevated fear-avoidance beliefs and appropriately modify the plan of care. The purpose of this case report is to describe the physical therapist management of a patient with acute LBP and elevated fear-avoidance beliefs.

Case Description

History

The patient was a 42-year-old man who was referred for physical therapy by his family medicine physician for examination and management of "acute lumbosacral strain." He was employed as a sales manager, had medical insurance, did not smoke, reported no significant past medical history, and reported no previous history of LBP that limited his activities. The patient's injury was not work-related and occurred 2 weeks before referral for physical therapy when he was lifting a heavy suitcase into the trunk of his car. He felt left-sided LBP that radiated into his left buttock and the anterior and medial portions of his left lower extremity. The pain originally radiated below the knee, but had not done so for the week prior to the physical therapist examination. A magnetic resonance imaging scan indicated that the patient had a herniated nucleus pulposus without nerve root comproulise at the L4-L5 level.

The patient described the nature of his LBP as a "deep ache" and constant, but it varied in intensity. The nature of his lower-extremity pain was described as "stabbing" and intermittent. The patient noted that prolonged sitting worsened his LBP and limited his ability to travel for work, although he had not yet missed any days of work. He felt better in the morning, with the pain gradually worsening throughout the day. The patient reported that his most comfortable position was lying fiat on his back, and he spent most of his time at home in that position, limiting his recreational activity. He could not identify any factors that consistently reproduced his left lower-extremity symptoms.

Hypothesis formation and direction for examination. The physical therapist formulated 3 questions to address during the examination. The first question involved the patient's history, of pain radiating into the lower extremity and occasionally below the knee. This symptom could be consistent with compressive nerve root injury and potentially warrant referral to another health care practitioner. The second question involved the appropriate treatment-based classification for physical therapy intervention. The patient noted a postural component (increased pain with sitting) that would be consistent with intervention emphasizing extension movements of the lumbar spine. (27,28) The third question was to consider the amount of avoidance behavior the patient had. The patient said that he had reduced his physical activity in response to LBP, and the physical therapist wanted to quantify the level of avoidance behavior to determine if modifications to the patient's plan of care were warranted.

Examination

Systems review. The neuromuscular system was reviewed to determine if the patient had signs of nerve root compression. The musculoskeletal system was reviewed to investigate the presence of impairments or functional limitations that were relevant to making a classification of LBP. Affect and cognition style were reviewed to provide an understanding of the patient's expected emotional and behavioral responses to an episode of LBP, based on the level of fear-avoidance beliefs. A review of the patient's other body systems was not performed at this time because he had a definite onset mechanism of LBP and did not have a past medical history suggestive of systemic or visceral sources of LBP.

Tests and measures. Examination findings from the neuromuscular and musculoskeletal systems are summarized in Table 2. Sacroiliac joint (SIJ) dysfunction was assessed by determining the symmetry of the patient's posterior superior iliac spines and performing special tests purported to test the alignment and movement of the SIJ. (27) The individual interrater reliability for the procedures used to determine SIJ dysfunction has been described as poor (kappa=0.19-0.37). (29) We made the decision about the presence of SIJ dysfunction from a composite of tests, which has been associated with less error (kappa=0.88). (30) A recent report, (29) however, suggests that substantial error also can be expected when using a composite of SIJ tests (kappa=0.11-0.23). A bubble goniometer * was used to measure range of motion for total lumbar flexion and straight leg raising. (31) The techniques that we used have been previously described in the literature, as has the reliability associated with measurements of range of motion for total lumbar flexion (intraclass correlation coefficient [ICC]-.94) and straight leg raising (ICC=.94 for right side, ICC=.96 for left side). (31) A "positive" straight-leg-raising test was defined as one that reproduced the patient's symptoms in the low back or lower extremity. A "negative" straight-leg-raising test was defined as one that did not reproduce the patient's symptoms in the low back or lower extremity. (32)

The effect of repeated lumbar movements on the patient's status also was measured during the examination. McKenzie (28) originally described this technique, and it involves determining if lumbar movements result in centralization (improvement in a patient's status by abolishing the symptoms or moving the symptoms to a more proximal location) or peripheralization (worsening of a patient's status by creating the symptoms or moving the symptoms to a more distal location). Lumbar movements that have no effect on the patient' status, briefly decrease the patient's symptoms, or briefly increase the patient's symptoms are labeled as a "status-quo" response. (27) The interrater reliability for physical therapists determining the effect of lumbar movements on the patient's status has been reported in the literature (kappa=0.82). (33)

The patient's affect and cognition style were measured by administering a self-report questionnaire. The FABQ (15) was used to quantify the patient's level of fear of pain and beliefs about the need to change behavior to avoid pain in response to an episode of LBP. The FABQ has 16 items, each scored from 0 to 6, with higher numbers indicating increased levels of fear-avoidance beliefs (Appendix). Two subscales are contained within the FABQ: a 7-item work subscale scale (score range=0-42) and a 4-item physical activity subscale (score range=0-24). Higher FABQ scores indicate higher amounts of fear-avoidance beliefs for both scales. (34-36) The test-retest stability of the FABQ has been reported (kappa for individual items=0.74), and the measure is believed to have validity because it explains additional amounts of variance in work loss (26%) and disability (23%) after controlling for pain intensity and location. (15)

Evaluation

Diagnosis. The physical therapist did not believe that the patient's symptoms were the result of a compressive nerve root injury because the straight-leg-raising test did not reproduce the patient's lower-extremity symptoms, the straight-leg-raise measurement exceeded 40 degrees, and the patient had normal and symmetrical findings for muscle, sensory, and reflex testing of the lower extremities. (32,37) Therefore, referral to another health care practitioner was unwarranted, and the physical therapist's diagnosis for this patient was "impaired joint mobility, motor function, muscle performance, range of motion, and reflex integrity associated with spinal disorders." (38)(p223) The cluster of symptoms, signs, and impairments guided treatment-based classification for physical therapist management. The SIJ tests were consistently symmetrical, so management for SIJ dysfunction was not warranted. (27,30) Neither centralization nor peripheralization of his symptoms was observed during the examination, but the physical therapist believed that intervention that emphasized lumbar extension movements was still most appropriate for this patient. (27,28) This decision was based on the patient's postural preference, the temporary decrease in symptoms noted with lumbar extension movements, and the therapist's clinical experience.

Prognosis and plan of care. Elevated fear-avoidance beliefs have been linked to prolonged disability, (11,12) and the physical therapist used the FABQ to determine the patient's prognosis. Because the patient's injury was not work-related, the therapist used the physical activity scale of the FABQ. Although cutoff scores for the FABQ physical activity scale have not been proposed, it has been suggested that scores exceeding 15/24 are "high," and this corresponds to our clinical experience. (16) The patient's FABQ physical activity, score was 21/24, which suggested that he was likely to be an "avoider." Therefore, we believed that he could be at an increased risk for prolonged disability from LBP. We were unable to estimate the increased risk for prolonged disability because likelihood ratios relating to this cutoff score are not known.

The physical therapist decided that the patient's plan of care should consist of exercises that emphasized repeated lumbar extension movements, graded exercise prescription, and fear-avoidance-based patient education. The rationale for this plan of care was that emphasizing lumbar extension movements would address the neuromuscular and musculoskeletal examination findings, whereas graded exercise prescription and fear-avoidance-based patient education would address the cognition and affect style examination findings. The therapist believed this approach would decrease this patient's chance of having prolonged disability from LBP. The physical therapist set an intervention frequency of 2 times a week for 4 weeks, based on clinical experience. The physical therapist planned to informally re-examine the patient and document pain intensity before each session, with a formal re-examination planned only if the patient's status warranted. A formal re-examination was planned for the fourth week, as that is when most change is observed during the first 6 months of an episode of LBP. (39)

Intervention

The patient's intervention consisted of exercises that emphasized lumbar extension, graded exercise prescription, and patient education. Each component was hypothesized to make a specific contribution to patient management. Graded exercise principles, (21,22) for example, were used to progress exercise, but not to determine the type of exercises prescribed.

Lumbar Extension Intervention

The physical therapist relied on principles emphasizing lumbar extension movements when determining the type of exercise to prescribe. The literature provides exercise recommendations to reinforce lumbar extension and discourage lumbar flexion for such patients. (27,28) The physical therapist prescribed prone press-ups, quadruped hip extension, and bridging exercise as a way to emphasize lumbar extension for this patient. The therapist also included treadmill walking for the patient because it was a way for him to perform an endurance activity while maintaining lumbar extension. The physical therapist added an abdominal strengthening exercise for the last 3 sessions to introduce a stabilization component into the patient's exercise prescription. (27) The physical therapist also prescribed hamstring muscle stretching exercise because of the flexibility deficit noted during the examination. Table 3 includes details of all of the exercises.

Fear-Avoidance Intervention

The physical therapist relied tn graded exercise principles when progressing the patient's exercise prescription. The therapist hypothesized that this would encourage the patient to be a "confronter" and decrease the patient's elevated fear-avoidance beliefs. The principles used in a graded exercise program were originally described by Fordyce et al. (21) The process used for this patient was based on those principles and is summarized in the Figure. The intensity, duration, and frequency of exercise selected for the initial exercise quota were based on the patient's pain intensity and current activity level. The patient's pain intensity was monitored during treatment sessions, but it was not used to make decisions regarding exercise progression.

Patient Education

The physical therapist used a specific, fear-avoidance-based education to complement the graded exercise prescription and encourage confrontation. The patient was given The Back Book pamphlet. (19) Previously, patients were issued the pamphlet, with no mention of further interaction between the patient and the health care practitioner.16 In this case, the physical therapist attempted to enhance the way the pamphlet is typically delivered by reinforcing the pamphlet's key principles (Tab. 1) and encouraging patient-therapist interaction during treatment sessions. For example, the patient was not explicitly instructed to avoid prolonged or extreme flexion postures, as would commonly be done when using an extension-based approach. The rationale was that the explanation for avoiding flexion was primarily anatomically based and could enhance avoidance behavior. Furthermore, when the patient inquired about when he should resume his recreational activities, the therapist told the patient about the importance of resuming normal activities while participating in rehabilitation for a low back injury.

This patient was seen for 6 physical therapy sessions (2 times a week for 3 weeks) after the initial examination, and details are summarized in Table 3. He met his exercise quota each session, and, as a result, his exercise prescription increased for each subsequent treatment session. The patient's home exercise program consisted of the same exercises he performed in the clinic. The rationale for replicating clinic and home exercises was the relatively short-term nature of the plan of care and the patient's difficulty performing some of the exercises correctly. For his home exercise program, the patient performed timed walking in his neighborhood because he did not own a treadmill. The patient's goal was to perform the home exercise program once a day. The patient read The Back Book pamphlet19 as part of his home exercise program.

Outcome

The measured outcomes for this patient were disability from LBP, fear-avoidance beliefs, and pain intensity. Physical impairments were assessed before the initial physical therapy session and 4 weeks after the start of intervention. The patient completed self-report questionnaires before the initial physical therapy session, 4 weeks after starting physical therapy, and 6 months after starting physical therapy. The 6-month questionnaire was returned by mail and provided additional information on the number of episodes of LBP, additional health care utilization, and satisfaction with intervention. The patient was given standard instructions for completing the questionnaires, and at no time did the physical therapist assist the patient in completing the questionnaires.

Disability

Low back-related disability was assessed with the Oswestry Disability Questionnaire (ODQ), a 10-item scale originally described by Fairbank et al. (40) Each item is scored from 0 to 5, and the final score is expressed as a percentage, with higher numbers indicating greater disability. The original ODQ has been modified by substituting a section regarding employment/homemaking ability for the section related to sex life. (41,42) This modified version of the ODQ has been found to have high levels of reliability (ICC= .90) for patients with LBP, construct validity (correlations with global patient ratings and other region-specific disability measures >.80), and responsiveness (effect size of 1.8 in patients receiving physical therapy interventions for LBP). (43) A minimal clinically important difference (MCID) of 6 points has been proposed for the ODQ. (43,44)

Fear-Avoidance Beliefs

The FABQ measured fear-avoidance beliefs about physical activity and work. An MCID of 4 points has been hypothesized for the physical activity scale of the FABQ-PA, but no MCID has been hypothesized for the work scale. (16)

Pain Intensity

The patient was asked to rate his current level of LBP intensity using an 11-point scale pain rating scale ranging from 0 ("no pain") to 10 ("worst imaginable pain"). He was asked to rate his pain intensity during 3 different conditions during the past 24 hours: present level of pain, best level of pain (least intense), and worst level of pain (most intense). The validity of patient self-reports of pain intensity and the discrimination capability of 11-point ordinal scales have been documented. (45,46) When a similar assessment technique was used, an MCID of 2 points was proposed for changes in pain intensity measures. (44)

Outcome Summary

Physical impairment outcomes are summarized in Table 2, and self-report outcomes are summarized in Table 4. An improvement was noted in straight-leg-raising range of motion at 4 weeks, although it is difficult to determine if this improvement was of clinical consequence, because the MCID for the straight leg raise is not known (Tab. 2). The patient experienced improvements that exceeded the MCID for disability from LBP, fear-avoidance beliefs, and pain intensity (Tab. 4). The patient exceeded his rehabilitation goals at 4 weeks; therefore, he was instructed to continue his home exercise program, and he was discharged from physical therapy.

The patient returned a packet that included the self-report questionnaires 6 months after intervention. He reported a large increase in his fear-avoidance beliefs (physical activity and work scales) and a smaller increase in his disability from LBP (Tab. 4). These increases exceeded the MCID thresholds. The patient indicated that he had had less than 2 additional episodes of LBP that interfered with his activity over the past 6 months. He had sought no additional physical therapy, but his physician prescribed Vicodin ([dagger]) or management of his LBP. At 6 months, the patient noted that he was "somewhat satisfied" with his present symptoms, would "definitely" have the same physical therapy intervention again, and felt the overall results from the physical therapy received were "excellent."

Discussion

Aspects of physical therapist management highlighted in this case paralleled what has been suggested in the literature for patients with elevated fear-avoidance beliefs. (14) The identification of a psychosocial factor (ie, elevated fear-avoidance beliefs) believed to be a precursor to prolonged disability was consistent with secondary prevention, which aims to reduce disability from LBP by limiting progression from acute to chronic LBP. (1,3) The intervention encouraged the patient, who had elevated fear-avoidance beliefs (ie, more likely to be an "avoider"), to confront his LBP through graded exercise and fear-avoidance-based patient education. Confrontation was selected as a theme for this patient's intervention because, within the theoretical framework of the FAMEPP, it is associated with symptom resolution and functional improvement. (7,8)

Physical therapist management that encourages confrontation of symptoms may seem counterintuitive to clinicians who are accustomed to working with patients with acute LBP. Therefore, it is important to note that we are not advocating that this intervention be used for all patients with acute LBP. Key examination findings played an important role in determining the appropriateness of this intervention approach. For example, we would not recommend the use of this intervention approach for patients with suspected or confirmed fracture, peripberalization of symptoms with lumbar movements, or signs and symptoms of nerve root compression. The FAMEPP does not account for such patients, and their avoidance behavior may be appropriate. Furthermore, we would not recommend the use of this intervention approach for patients not having elevated fear-avoidance beliefs. These patients would already be likely to confront their symptoms, making treatment augmentation unnecessary. There also may be some concern among clinicians that confrontation of symptoms could harm patients with acute LBP. Anecdotally, this confrontation in patients with acute symptoms has not been consistent with our clinical experience, and researchers (22,47,48) investigating similar types of behavioral interventions did not report adverse events. In fact, these researchers (22,47,48) reported patient outcomes that consistently favor the behavioral intervention approach. More research is needed to identify patient characteristics that are associated with a positive response to this approach and to confirm that no harm is done by encouraging confrontation of symptoms.

Initially, this patient had moderate disability from LBP with elevated fear-avoidance beliefs and minor physical impairment. The patient's plan of care addressed each of these factors because they could have contributed to disability from LBP. Four weeks later, the patient's self-report indicated a large, clinically significant improvement. This improvement was accompanied by a debatable improvement in straight leg raise and a clinically significant improvement in fear-avoidance beliefs about physical activity. We believed that the improvement in disability was primarily due to the decrease in the fear-avoidance beliefs, because such an improvement would not have been expected from the change in physical impairment alone. Because of the limitations associated with a case report, this observation does not imply that the improvement in disability was caused by a decrease in fear-avoidance beliefs.

Clinically meaningful increases in disability and fear-avoidance beliefs were observed at 6 months. Unfortunately, the reasons for this regression in status were not clear, partially due to the limitations of the follow-up assessment. The 6-month assessment did not account for any changes in activity level, work status, or adherence to the home program that may have contributed to the observed increases in disability and fear-avoidance beliefs. The patient stated that his physician had prescribed Vicodin to manage his LBP, and this could have accounted for the low pain intensity scores at 6 months. This is also a tenuous assumption, however, because the follow-up assessment determined only whether the patient had taken Vicodin since being discharged from physical therapy, not whether he was currently taking the drug. Despite the regression, the patient continued to have substantial improvement in 6-month disability when compared with the initial therapy session.

There seems to be a consensus that an active approach is more effective than a passive approach for management of acute LBP. (49,50) In addition, the behavioral literature suggests that optimal management strategies for patients with acute LBP should not limit activity- because of pain. (47,48) The avoidance of passive interventions and pain-limited intervention protocols may be particularly important for patients with elevated fear-avoidance beliefs because they may never learn to confront activities that are perceived to be potentially pain provoking. Reliance on passive or pain-limited protocols may actually perpetuate and exacerbate fear-avoidance beliefs for such patients. Graded exercise emphasizes activity tolerance and de-emphasizes pain abatement, and we believe it should be considered for patients with elevated fear-avoidance beliefs, despite the lack of direct evidence.

When compared with a traditional educational approach, fear-avoidance-based patient education has resulted in positive shifts in patient beliefs, but not in significant differences in amounts of posttreatment disability. (16,18) The approach that we used differed from previously described approaches because the physical therapist reinforced information from The Back Book pamphlet (19) during subsequent patient visits. We believe that this approach has the potential to improve patients' fear-avoidance beliefs and disability because of additional patient-therapist interactions that occur after The Back Book pamphlet (19) is issued. Research is needed, however, before the beneficial effect of this type of educational approach can be confirmed.

The implications of our patient's outcomes are limited because this is a case report, but we theorize that physical therapist management may have to be altered from what we described to have a long-term effect on fear-avoidance beliefs. Some authors (51) have suggested that, for patients with elevated fear-avoidance beliefs, the most appropriate active intervention is one that gradually exposes patients to the feared condition (graded exposure), not one that gradually increases patients' tolerance to activity (graded exercise). (52) Another possibility is that fear-avoidance beliefs may be a state-specific (ie, exist only when person is experiencing LBP) extension of a basic personality trait, such as coping style. Therefore, patient education may have to be more comprehensive than what we described. Physical therapists may have to consider consultation with other health care practitioners who specialize in mental health problems to effectively manage patients with elevated fear-avoidance beliefs. Research on different fear-avoidance-based interventions needs to be completed before its effects on long-term disability and fear-avoidance beliefs are known.

Physical therapist management of a patient with acute LBP and elevated fear-avoidance beliefs has not been previously described in the literature, and evidence supporting its effectiveness does not exist. This case report described physical therapist management for a patient with acute LBP and elevated fear-avoidance beliefs. The intervention approach was theory based, with adjustments made from our collective clinical experiences. We believe that this intervention approach represented an effective way to manage a patient with elevated fear-avoidance beliefs, but experimental evidence to validate our beliefs is lacking. Research using appropriate study designs (eg, randomized clinical trials) will provide more definitive information on the effectiveness of the physical therapist management approach.

Appendix.
Fear-Avoidance Beliefs Questionnaire (a)

Here are some of the things other patients have told us about their
pain. For each statement, please mark the number from 0 to 6 to
indicate how much physical activities such as bending, lifting,
walking, or driving affect or would affect your back pain.

                            Completely                       Completely
                            Disagree     Unsure              Agree

 1. My pain was caused by   0            1   2   3   4   5   6
    physical activity
 2. Physical activity       0            1   2   3   4   5   6
    makes my pain worse
 3. Physical activity       0            1   2   3   4   5   6
    might harm my back
 4. I should not do         0            1   2   3   4   5   6
    physical activities
    which (might) make my
    pain worse
 5. I cannot do physical    0            1   2   3   4   5   6
    activities which
    (might) make my pain
    worse

The following statements are about how your normal work affects or
would affect your back pain.

                            Completely                       Completely
                            Disagree     Unsure              Agree

 6. My pain was caused by   0            1   2   3   4   5   6
    my work or by an
    accident at work
 7. My work aggravated my   0            1   2   3   4   5   6
    pain
 8. I have a claim for      0            1   2   3   4   5   6
    compensation for my
    pain
 9. My work is too heavy    0            1   2   3   4   5   6
    for me
10. My work makes or        0            1   2   3   4   5   6
    would make my pain
    worse
11. My work might harm my   0            1   2   3   4   5   6
    back
12. I should not do my      0            1   2   3   4   5   6
    regular work with my
    present pain
13. I cannot do my normal   0            1   2   3   4   5   6
    work with my present
    pain
14. I cannot do my normal   0            1   2   3   4   5   6
    work until my pain is
    treated
15. I do not think that I   0            1   2   3   4   5   6
    will be back to my
    normal work within 3
    months
16. I do not think that I   0            1   2   3   4   5   6
    will ever be able to
    go back to that work

(a) Reprinted from Waddell G, Newton M, Henderson I, et al. A
Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of
fear-avoidance beliefs in chronic low back pain and disability. Pain.
1993;52:157-168. Copyright 1993, with permission from International
Association for the Study of Pain.

Table 1.
Key Principles From Educational Pamphlets Based on Different Models of
Low Back Pain (16)

Handy Hints (20)                      The Back Book (19)
(Biomedical Model)                    (Fear-Avoidance Model)

Traditional biomedical concepts of    No sign of serious disease or
  spine anatomy, injury, and damage     suggestion of permanent damage
                                        for patients with nonspecific
                                        low back pain

Avoid activity when in pain           The spine is strong, and spine
                                        pain does not necessarily mean
                                        your back has any serious
                                        damage

Describes further interventions,      A number of treatments can help
  including surgery                     to control the pain, but
                                        lasting relief depends on your
                                        effort

Concentrates on pain, rather than     Concentrates on activity to
  activity                              restore normal function and
                                        fitness

Encourages patient to be passive      Encourages positive attitudes and
                                        coping

Table 2.
Neuromuscular and Musculoskeletal Examination Findings

Examination Procedure          Initial Evaluation   4 Weeks

Sacroiliac joint testing
  Symmetry of PSISs (a)        Negative
  Standing flexion test        Positive
  Prone knee flexion test      Negative
  Supine long sitting test     Negative

Lumbar movement testing
  Flexion                      Status quo           Status quo
  Extension                    Status quo           Status quo
                                 (decreased)
  Left side bending            Status quo           Status quo
                                 (increased)
  Right side bending           Status quo           Status quo
                                 (increased)

Total lumbar flexion           95 [degrees]         95 [degrees]

Straight leg raise
  Right                        65 [degrees],        70 [degrees],
                                 negative             negative
  Left                         65 [degrees],        75 [degrees],
                                 negative             negative

Nonorganic symptoms            1                    Not assessed

Nonorganic signs               0                    0

Sensory examination
  L1 (inguinal area)           Right: normal,       Not assessed
                                 left: normal
  L2 (anterior mid-thigh)      Right: normal,
                                 left: normal
  L3 (distal anterior thigh)   Right: normal,
                                 left: normal
  L4 (medial lower leg)        Right: normal,
                                 left: normal
  L5 (lateral leg/foot)        Right: normal,
                                 left: normal
  S1 (lateral side of foot)    Right: normal,
                                 left: normal

Motor examination
  L2-L3 (hip flexion)          Right: 5/5,          Right: 5/5,
                                 left: 5/5            left: 5/5
  L3-L4 (knee extension)       Right: 5/5,          Right: 5/5,
                                 left: 5/5            left: 5/5
  L4 (dorsiflexion)            Right: 5/5,          Right: 5/5,
                                 left: 5/5            left: 5/5
  L5 (hallux extension)        Right: 5/5,          Right: 5/5,
                                 left: 5/5            left: 5/5
  S1-S2 (ankle eversion)       Right: 5/5,          Right: 5/5,
                                 left: 5/5            left: 5/5

Deep tendon reflexes
  Quadriceps                   Right: normal,       Not assessed
                                 left: normal
  Achilles                     Right: normal,
                                 left: normal

(a) PSISs=posterior superior iliac spines.

Table 3.
Summary of Physical Therapy Sessions

Physical Therapy Session 1

Pre-exercise pain intensity
  4/10

Therapeutic exercise
  Prone press-ups, 2 x 10
  Quadruped hip extension, 2 x 10
  Bridging, 2 x 10
  Hamstring muscle stretch 4 x 30 s
  Treadmill ambulation 2.0 mph x 30 min

Post-exercise pain intensity
  4/10

Met exercise quota?
  Yes

Patient participation
  Reported he read pamphlet
  Performed home exercise program

Physical Therapy Session 2

Pre-exercise pain intensity
  3/19

Therapeutic exercise
  Prone press-ups, 2 x 12
  Quadruped hip extension, 2 x 12
  Bridging, 2 x 12
  Hamstring muscle stretch 4 x 30 s
  Treadmill ambulation 2.4 mph x 30 min

Post-exercise pain intensity
  3/10

Met exercise quota?
  Yes

Patient participation
  Performed home exercise program

Physical Therapy Session 3

Pre-exercise pain intensity
  7/10

Therapeutic exercise
  Prone press-ups, 2 x 14
  Quadruped hip extension, 2 x 15
  Bridging, 2 x 15
  Hamstring muscle stretch 4 x 30 s
  Treadmill ambulation 2.8 mph x 30 min

Post-exercise pain intensity
  7/10

Met exercise quota?
  Yes

Patient participation
  Performed home exercise program

Physical Therapy Session 4

Pre-exercise pain intensity
  3/10

Therapeutic exercise
  Prone press-ups, 3 x 10
  Quadruped hip extension 2 x 20
  Bridging, 2 x 20
  Hamstring muscle stretch 4 x 30 s
  Abdominal hollowing 10 x 10 s
  Treadmill ambulation 2.8 mph x 35 min

Post-exercise pain intensity
  2/10

Met exercise quota?
  Yes

Patient participation
  Performed home exercise program

Physical Therapy Session 5

Pre-exercise pain intensity
  2/10

Therapeutic exercise
  Prone press-ups, 3 x 12
  Quadruped hip extension 2 x 25
  Bridging, 2 x 25
  Hamstring muscle stretch 4 x 30 s
  Abdominal hollowing 15 x 10 s
  Treadmill ambulation 2.8 mph x 40 min

Post-exercise pain intensity
  1/10

Met exercise quota?
  Yes

Patient participation
  Performed home exercise program

Physical Therapy Session 6

Pre-exercise pain intensity
  1/10

Therapeutic exercise
  Prone press-ups, 3 x 15
  Quadruped hip extension 2 x 30
  Bridging, 2 x 30
  Hamstring muscle stretch 4 x 30 s
  Abdominal hollowing 20 x 10 s
  Treadmill ambulation 3.0 mph x 45 min

Post-exercise pain intensity
  1/10

Met exercise quota?
  Yes

Patient participation
  Performed home exercise program

Table 4.
Summary of Disability, Fear-Avoidance, and Pain Intensity Measures

Measure                         Initial   4 Weeks   6 Months

Disability                       52%       16%        22%
  Oswestry Disability
    Questionnaire
  (0%-100%)

Fear-avoidance beliefs           21         6         15
  (physical activity)
  FABQ (a) physical activity
    scale (0-24)

Fear-avoidance beliefs (work)     0         0         14
  FABQ work scale (0-42)

Pain intensity (at present)       6/10      1/10       2/10
  Ordinal scale (0-10)

Pain (at worst)                   9/10      2/10       2/10
  Ordinal scale (0-10)

Pain (at best)                    3/10      0/10       1/10
  Ordinal scale (0-10)

(a) FABQ=Fear-Avoidance Beliefs Questionnaire.

Support for this case report was provided by a PODS II scholarship from the Foundation for Physical Therapy.

* Vigor Equipment Inc, 4915 Advance Way, Stevensville, MI 49127.

([dagger]) Abbott Laboratories, Pharmaceutical Products Division, North Chicago, IL 60064.

References

(1) Frank JW, Kerr MS, Brooker AS, et al. Disability resulting from occupational low back pain, part I: what do we know about primary prevention? A review of the scientific evidence on prevention before disability begins. Spine. 1996;21:2908-2917.

(2) Spitzer WO. Magnitude of the problem. Spine. 1987;12(suppl):12-25.

(3) Frank JW, Brooker AS, DeMaio SE, et al. Disability resulting from occupational low back pain, part II: what do we know about secondary prevention? A review of the scientific evidence on prevention after disability begins. Spine. 1996;21:2918-2929.

(4) Burton AK, Tillotson KM, Main CJ, Hollis S. Psychosocial predictors of outcome in acute and subchronic low back trouble. Spine. 1995;20: 722-728.

(5) Gatchel RJ, Polatin PB, Mayer TG. The dominant role of psychosocial risk factors in the development of chronic low back pain disability. Spine. 1995;20:2702-2709.

(6) Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine. 2002;27:E109-E120.

(7) Slade PD, Troup JDG, Lethem J, Bentley G. The fear-avoidance model of exaggerated pain perception: II. Behav Res Ther. 1983;21: 409-416.

(8) Lethem J, Slade PD, Troup JDG, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception: I. Behav Res Ther. 1983;21:401-408.

(9) Bortz WM. The disuse syndrome. West J Med. 1984;141:691-694.

(10) Kottke FJ. The effects of limitation of activity upon the human body. JAMA. 1996;196:117-122.

(11) Klenerman L, Slade PD, Stanley IM, etal. The prediction of chronicity in patients with an acute attack of low back pain in a general practice setting. Spine. 1995;20:478-484.

(12) Fritz JM, George SZ, Delitto A. The role of fear avoidance beliefs in acute low back pain: relationships with current and future disability and work status. Pain. 2001;94:7-1:5.

(13) Fritz JM, George SZ. Identifying specific psychosocial factors in patients with acute, work-related low back pain; the importance of fear-avoidance beliefs. Phys Ther. 2002;82:973-983.

(14) Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;8:5:317-332.

(15) Waddell G, Newton M, Henderson I, et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993;52:157-168.

(16) Burton AK, Waddell G, Tillotson KM, Summerton N. Information and advice to patients with back pain can have a positive effect: a randomized controlled trial of a novel educational booklet in primary care. Spine. 1999;24:2484-2491.

(17) Hazard RG, Reid S, Haugh LD, McFarlane G. A controlled trial of an educational pamphlet to prevent disability after occupational low back injury. Spine. 2000;25:1419-1423.

(18) Symonds TL, Burton AK, Tillotson KM, Main CJ. Absence resulting from low back trouble can be reduced by psychosocial intervention at the work place. Spine. 1995;20:2738-2745.

(19) Roland M. Waddell G, Klaher-Moffett K, etal. The Back Book. Norwich, United Kingdom: The Stationery Office; 1996.

(20) Handy Hints: Basic Back Education and Treatment. London, United Kingdom: National Back Pain Association; 1994.

(21) Fordyce WE, Fowler RS, Lehmann JF, et al. Operant conditioning in the treatment of chronic pain. Arch Phys Med Rehabil. 1973;54:399-408.

(22) Lindstrom I, Ohlund C, Eek C, et al. The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioral approach. Phys Ther. 1992;72:279-290.

(23) Faas A. Exercises: which ones are worth trying, for which patients, and when? Spine. 1996;21:2874-2878.

(24) van Tulder MW, Kues BW, Bouter LM. Conservative treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine. 1997;22:2128 -2156.

(25) Moffett JK, Torgerson D, Bell-Syer S, et al. Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and preferences. BMJ. 1999;319:279-283.

(26) van Tulder MW, Malmivaara A, Esmail R, Koes BW. Exercise therapy for low back pain: a systematic review within the framework of the Cochrane Collaboration back review group. Spine. 2000;25: 2784-2796.

(27) Delitto A, Erhard RE, Bowling RW. A treatment-based classification approach to low back syndrome: identifying and staging patients for conservative treatment. Phys Ther. 1995;75:470-485; discussion 485-489.

(28) McKenzie PA. The Lumbar Spine: Mechanical Diagnosis and Therapy. Waikanae, New Zealand: Spinal Publications Ltd; 1989.

(29) Riddle DL, Freburger.lK. Evaluation of the presence of sacroiliac joint region dysfunction using a combination of tests: a multicenter intertester reliability study. Phys Ther. 2002;82:772-781.

(30) Cibulka MT, Delitto A, Koldehoff RM. Changes in innominate tilt after manipulation of the sacroiliac joint in patients with low back pain: an experimental study. Phys Ther. 1988;68:1359-1363.

(31) Waddell G, Somerville D, Henderson I, Newton M. Objective clinical evaluation of physical impairment in chronic low back pain. Spine. 1992;17:617-628.

(32) Vroomen PC, de Krom MC, Knottnerus JA. Diagnostic value of history and physical examination in patients suspected of sciatica due to disc herniation: a systematic review. J Neurol. 1999;246:899-906.

(33) Fritz JM, Delitto A, Vignovic M, Busse RG. lnterrater reliability of judgments of the centralization phenomenon and status change during movement testing in patients with low back pain. Arch Phys Med Rehabil. 2000;81:57-61.

(34) Asmundson GJ, Norton GR, Allerdings MD. Fear and avoidance in dysfunctional chronic back pain patients. Pain. 1997;69:231-623.

(35) Vlaeyen JW, Kole-Snijders AM, Boeren RG, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62:363-372.

(36) Vlaeyen JW, Kole-Snijders AM, Rotteveel AM, et al. The role of fear of movement/(re)injury in pain disability. J Occup Rehabil. 1995;5: 235-252.

(37) Vroomen PC, de Krom MC, Wilmink JT, et al. Diagnostic value of history and physical examination in patients suspected of lumbosacral nerve root compression. J Neurol Neurosurg Psychiatry. 2002;72:630-634.

(38) Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81: 9-746.

(39) Von Korff M, Saunders K. The course of back pain in primary care. Spine. 1996;21:2833-2837.

(40) Fairbank JC, Couper J, Davies JB, O'Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy. 1980;66:271-273.

(41) Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine. 2000;25:2940-2953.

(42) Roland M, Fairbank JC. The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire. Spine. 2000;25:3115-3124.

(43) Fritz JM, Irrgang JJ. A comparison of a modified Oswestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability Scale. Phys Ther: 2001;81:776-788.

(44) Beurskens AJ, de Vet HC, Koke AJ. Responsiveness of functional status in low back pain: a comparison of different instruments. Pain. 1996;65:71-76.

(45) Price DD, McGrath PA, Rafii A, Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain. 1983;17:45-56.

(46) Jensen MP, Turner (JA), Romano JM. What is the maximum number of levels needed in pain intensity measurement? Pain. 1994;58: 387-392.

(47) Linton SJ, Hellsing AL, Andersson D. A controlled study of the effects of an early intervention on acute musculoskeletal pain problems. Pain. 1993;54:353-359.

(48) Fordyce WE, Brockway JA, Bergman JA, Spengler D. Acute back pain: a control-group comparison of behavioral vs traditional management methods. J Behav Med. 1986;9:127-140.

(49) Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered: a randomized clinical trial. Spine. 1995;20: 473-477.

(50) Hagen EM, Eriksen HR, Ursin H. Does early intervention with a light mobilization program reduce long-term sick leave for low back pain? Spine. 2000;25:1973-1976.

(51) Vlaeyen JW, de Jong J, Geilen M, et al. Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain. Behav Res Ther. 2001;39:151-166.

(52) Vlaeyen JW, de Jong J, Geilen M, et al. The treatment of fear of movement/(re)injury in chronic low back pain: further evidence on the effectiveness of exposure in vivo. Clin J Pain. 2002;18:251-261.

SZ George, PT, PhD, is Assistant Professor, Department of Physical Therapy, Brooks Center for Rehabilitation Study, University of Florida, PO Box 100154, Gainesville, FL 32610-0154 (USA) ([e-mail]). Address all correspondence to Dr George.

JE Bialosky, PT, MS, OCS, FAAOMPT, is Physical Therapist, Concentra Medical Center, Pittsburgh, Pa.

JM Fritz, PT, PhD, ATC, is Assistant Professor, Division of Physical Therapy, University of Utah, Salt Lake City, Utah.

Dr George and Dr Fritz provided concept/idea/project design and writing. Dr George and Mr Bialosky provided data collection and project management. Dr George provided fund procurement, and Mr Bialosky provided the patient and facilities/equipment. The authors acknowledge G Kelley Fitzgerald, PT, PhD, OCS, and Anthony Delitto, PT, PhD, FAPTA, for their review of a previous draft of the manuscript.

This article was received May 1, 2003, and was accepted November 16, 2003.