The Spine Journal 11 (2011) 895–903

Review Article

Fear-avoidance beliefs and pain avoidance in low back pain—translatingresearch into clinical practice

James Rainville, MDa,b,*, Rob J.E.M. Smeets, MD, PhDc, Tom Bendix, MDd,Torill H. Tveito, PhDe,f, Serge Poiraudeau, MD, PhDg, Aage J. Indahl, MD, PhDe,h

aDepartment of Physical Medicine and Rehabilitation, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USAbThe Spine Center, New England Baptist Hospital, 125 Parker Hill Ave., Boston, MA 02120, USA

cDepartment of Rehabilitation Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The NetherlandsdCopenhagen Spine Center, Glostrup University Hospital, Glostrup, Denmark

eDepartment of Health Promotion and Development, University of Bergen, Bergen, NorwayfHarvard School of Public Health, 677 Huntington Ave, Boston, MA 20115, USA

gAP-HP, Service de Medecine Physique et Readaptation, Hospital Cochin, Universite Paris Descartes, INSERM, SFR Handicap, Paris, FrancehHospital for Rehabilitation—Stavern, Rikshospitalet Medical Center, Oslo, Norway

Received 2 April 2011; accepted 4 August 2011

Abstract BACKGROUND CONTEXT: For patients w

FDA device/drug

Author disclosure

close. TB: Nothing to

disclose. AJI: Nothin

1529-9430/$ - see fro

doi:10.1016/j.spinee.2

ith low back pain, fear-avoidance beliefs (FABs)represent cognitions and emotions that underpin concerns and fears about the potential for physicalactivities to produce pain and further harm to the spine. Excessive FABs result in heightened dis-ability and are an obstacle for recovery from acute, subacute, and chronic low back pain.PURPOSE: This article summarizes past research concerning the etiology, impact, and assessmentof FABs; reviews the results and relevance to clinical practice of trials that have addressed FAB aspart of low back pain treatment; and lists areas in need of further study.STUDY DESIGN: This article reports on a plenary presentation and discussion of an expert paneland workshop entitled ‘‘Addressing fear-avoidance beliefs in a fear-avoidant world—translating re-search into clinical practice’’ that was held at Forum X, Primary Care Research on Low Back Pain,during June 2009, at the Harvard School of Public Health in Boston, MA, USA.METHODS: Important issues including the definition, etiology, impact, and treatment of FAB onlow back pain outcomes were reviewed by six panelists with extensive experience in FAB-relatedresearch. This was followed by a group discussion among 40 attendees. Conclusion and recommen-dations were extracted by the workshop panelist and summarized in this article.RESULTS: Fear-avoidance beliefs are derived from both emotionally based fears of pain andinjury and information-based beliefs about the soundness of the spine, causes of spine degener-ation, and importance of pain. Excessively elevated FABs, both in patients and treating healthcare providers, have a negative impact on low back pain outcomes as they delay recovery andheighten disability. Fear-avoidance beliefs may be best understood when patients are categorizedinto subgroups of misinformed avoiders, learned pain avoiders, and affective avoiders as thesecategories elucidate potential treatment strategies. These include FAB-reducing informationfor misinformed avoiders, pain desensitizing treatments for pain avoiders, and fear desensitiza-tion along with counseling to address the negative cognition in affective avoiders. Althoughmixed results have been noted, most clinical trials have documented improved outcomes whenFAB is addressed as part of treatment. Deficiencies in knowledge about brief methods for assess-ing FAB during clinical encounters, the importance of medical explanations for back pain,usefulness of subgroup FABs, core points for information-based treatments, and efficient strate-gies for transferring FAB-reducing information to patients hamper the translation of FABresearch into clinical practice.

status: Not applicable.

s: JR: Nothing to disclose. RJEMS: Nothing to dis-

disclose. THT: Nothing to disclose. SP: Nothing to

g to disclose.

* Corresponding author. The Spine Center, New England Baptist Hos-

pital, 125 Parker Hill Ave., Boston, MA 02120, USA. Tel.: (617) 754-

5146; fax: (617) 754-6332.

E-mail address: jrainvil@caregroup.harvard.edu (J. Rainville)

nt matter � 2011 Elsevier Inc. All rights reserved.

011.08.006

896 J. Rainville et al. / The Spine Journal 11 (2011) 895–903

CONCLUSIONS: By incorporating an understanding of FAB, clinicians may enhance their abilityto assess the predicaments of their patients with low back pain and gain insight into potential valueof corrective information that lessen fears and concerns on well-being of their patients. � 2011Elsevier Inc. All rights reserved.

Keywords: Disability; Fear avoidance; Pain avoidance; Pain beliefs; Cognitive behavioral treatment

Introduction

When faced with a difficult problem like low back pain,the mind routinely theorizes about the implications of symp-toms and considers the consequences of future actions. Ex-ploration of the thoughts of people disabled by low backpain have uncovered that many endorse disproportionatelystrong beliefs about the importance of back pain and the vul-nerability of the spine and as a consequence avoid activitiesthey ‘‘fear’’ will lead to additional pain and injury [1]. Thesedisadvantageous concerns were termed fear-avoidance be-liefs (FABs) by Lethem et al. [2]. It is recognized that exces-sive FAB and resultant disability have dire consequences forpatients. These include physical inactivity, reduced mentalwell-being, assumption of the sick role, deterioration in fam-ily dynamics, dependence onmedications, and excessive uti-lization of medical services [3–5].

Because of the direct consequences of heightened FABon the health and well-being of people with low back pain,it would seem beneficial for the health care system to un-derstand and address them. Regrettably, discoveries aboutFAB have not been widely translated into clinical practices.Many health care providers are not cognizant of the impor-tance of FAB and are subsequently unmindful about the po-tential for clinical encounters to positively or negativelyimpacting FAB. This omission may be partially responsiblefor the increasing level of disability reported by people withlow back pain in modern societies, despite ever increasingmedical expenditure for the care of this problem [6].

This article highlights important issues regarding FAB,including their influences on outcomes, assessment, treat-ment potential, and areas in need of further study. These ma-terials are based on presentations and discussions thatsurrounded a focused workshop entitled ‘‘Addressing fear-avoidance beliefs in a fear-avoidant world—translating re-search into clinical practice’’ at the Forum X, Primary CareResearch on Low Back Pain, held during June 2009, at theHarvard School of Public Health in Boston, MA, USA. Thisworkshop consisted of presentations by international panel-ists with extensive experience addressing/measuring/modi-fying back pain–related FAB in research and clinicalpractice. This was followed by expanded discussions be-tween panelist and workshop participants that explored ac-tual experiences with addressing FAB during medicalencounters. By summarizing the materials developed duringand in response to that workshop, this paper presents

a practical review of the importance of FAB to low back painthat may benefit practicing clinicians and future researchefforts.

What are FABs?

Fear is an emotional response generated during danger-ous or painful experiences and can include potentially use-ful survival mechanisms, such as escape and avoidancebehaviors [7]. Through classic conditioning, after experi-ences that stimulate low back pain, anticipated or actual ex-posures to similar experiences can reelicit a fear response,even when these experiences are neither harmful nor pain-ful. Fear can also be learned through vicarious exposure, in-cluding observing others with back pain (modeling) [8],and as a result of fear-inducing information about back pain[9,10]. It is likely that classic conditioning and vicariouslearning combine to produce fear of movements and phys-ical activities for some individuals with low back pain, withresultant reluctance to engage in normal physical activities,called fear-avoidance behaviors.

Although emotion-based fear may be a relevant factor ina subset of people, reason-based beliefs are important to allpeople with low back pain. Beliefs are defined as convictionsof the truth of propositions without their verification and assuch are subjective mental interpretations derived from per-ceptions, reasoning, or communications. All adults havemeasurable beliefs about back pain that encompass thoughtsabout the processes responsible for back pain, structuralsoundness of the spine, and risks to the spine associated withphysical activities [11]. These beliefs are likely derived frommultiple sources, including personal experiences, family, ac-quaintances, societal attitudes, media, low back literature,Internet research, and encounters with the health care sys-tem. Because human behaviors are shaped by beliefs, backpain beliefs directly influence decisions to perform or avoidpersonal, recreational, or vocational activities and thereforeunderpin the resultant level of ability/disability noted in re-sponse to back pain.

Impact of medical concepts about low back pain onFABs

In contrast to medical advances in many fields, dissem-ination of knowledge about the etiology of low back pain

897J. Rainville et al. / The Spine Journal 11 (2011) 895–903

remains sluggish. This quandary has kept the door open formany competing explanations with rival theories insinuat-ing different musculoskeletal, neurological, and psycholog-ical pathologies as the source of low back pain, each withimplication for prognosis, treatments, and prevention. Be-cause FABs are in part derived from conceptualizationsabout what is wrong with the back, assimilation of medicalexplanations for low back pain can enhance or diminishFABs as elucidated below.

For decades, biomechanical models were the predomi-nant explanations for spine degeneration and low back pain[12]. These efforts produced the ‘‘cumulative injury model,’’which postulated that exposure of the spine to mechanicalstresses generated during activities, such as prolonged orawkward positions, lifting, and physical exertion, injuredthe spinal tissues, with resultant pain [13]. This explanationimplied a vulnerability of the spine and suggested that reduc-tion of exposure to the offending activities was a logical partof injury prevention [14]. The resultant treatment strategiesincluded bed rest, activity avoidance, and ergonomic-basedwork restriction, all of which validated FABs. Unfortunately,the injury model has not withstood scientific validation asoccupational [15,16], ergonomic [17,18], psychosocial[19], magnetic resonance imaging [20], and symptom onsetstudies [21,22] have been unable to strongly link physical ex-posures to spinal degeneration or low back pain. Regardless,the assimilation of the injury model into the beliefs of bothhealth care providers and patients remains prevalent. Thisis not trivial, as in many ways, the magnitude of FABs, forboth health care providers and patients, is in large part reflec-tive of the degree to which one endorses or rejects the injurymodel of low back pain [23].

Now consider the implications on FABs of theories de-rived from new discoveries about the spine. Recent epide-miological and biological studies suggest that spinaldegeneration results from genetically predetermined factorsthat influence the function and survival of the cells respon-sible for maintenance of spine structures [24]. These find-ings infer that the age of onset and progression of spinaldegeneration are genetically preset and minimally influ-enced by exposure to physical and occupational activities[25]. Concurrently, neuroscientists discovered that manypersistent pain disorders (including low back pain) resultfrom central sensitization of nociceptive neurons, whichuncouple pain from harmful peripheral stimuli [26]. Thisresults in pain hypersensitivity in which low back paincan be evoked by innocuous normal stimulations of thespine and adjacent tissues, and therefore it lacks protectivefunction [27,28]. Other researchers discovered complex in-teractions between the nerve receptors within the connec-tive tissues of the spine and paraspinal muscle function[29]. They postulate that low back pain may result from ab-normalities of these interactions that may cause painful, butbenign, abnormal muscle tension. These theories offer in-sight about neurological mechanisms that cause persistentlow back pain without suggesting that pain indicated

ongoing damage to the spine. As such, these theories under-mine the concerns that physical activities harm the spineand thereby challenge the necessity of back pain–relateddisability. Assimilation of these theories should lessenFABs [30].

Importance of FABs

For general population

Because back pain is a common affliction that receivesconsiderable attention in modern societies, most people haveshaped opinions about its importance, causes, and conse-quences. Population surveys have shown that a range ofFABs exist within the general population, regardless of thepresence of back pain [31]. Most people have modest FABs,but a fair sector of the population is quite fear avoidant. Lon-gitudinal surveys reveal that heightened FABs are not incon-sequential. Segments of the population with heightenedbeliefs have increased risk for delayed recovery from acuteback pain episodes [32], greater work absence after the de-velopment of low back pain [33], and greater risk for the de-velopment of chronic disabling back pain [34].

For acute back pain

Although individuals start with intrinsic FABs, they arenormally heightened above baseline levels after exposure toacute severe low back pain [35,36]. Usually, however, thisshift is temporary and corresponds to when movementsare particularly painful. Heightened beliefs rapidly recedeas pain improves suggesting that many people extinguishelevated FAB as symptoms subside by successfully con-fronting them during the process of resumption of activities[35,37,38].

For some, however, heightened FAB persists or even esca-lates during acute back pain episodes [37]. This may simplyreflect a temporary consequence of persistence of severe painor more severe pathology. It also may represent maladapta-tion, where an unnecessary cycle of continued avoidanceof activities allows persistence of heightened fear avoidance,which promotes continued avoidance of activities. The latterexplanation is supported by observations that escalating FABduring acute back pain strongly correlates with rising dis-ability [39] and are predictive of the development of chronicback pain and disability [35,37,40–43].

For chronic low back pain

The consequences of elevated FAB are most sizable inchronic low back pain, where these beliefs are strongly as-sociated with disability. This association persists even aftercontrolling for pain intensity and other important covari-ables [44,45]. Elevated FAB in chronic low back pain influ-ences performance of functional physical tasks [46] and arestrong predictors of long-term work disability [32]. These

898 J. Rainville et al. / The Spine Journal 11 (2011) 895–903

observations suggest that FABs express the reasoning usedby patients to rationalize the degree to which they becomedisabled in the presence of chronic low back pain.

Unlike acute low back pain where elevated FABs aremitigated during recovery, in chronic low back pain, ele-vated FABs tend to remain unchanged over time [35,38].Surprisingly, persistence of FAB has been observed evenafter spine surgery [47,48] and physical therapy that wasfollowed by improvement in pain and other parameters[49,50]. Because heightened FAB directly influences dis-ability, the persistence of heightened FAB can dampenthe effectiveness of treatments for reducing disability [48].

For health care providers

In general, FABs held by health care providers are re-markably similar to those noted in the populations in whichthey practice [30], with health care providers being moder-ately fear avoidant overall [51]. A surprising finding is thathealth care providers’ FABs are remarkably similar acrossmedical disciplines and are minimally associated with edu-cation, spine expertise, or practice experience [52,53]. Thesefindings suggest that FABs result from deeply personal con-victions about pain and that many health care providers donot hold beliefs that result in high functional expectationsfor people with low back pain.

Just as FABs influence patients’ responses to their backpain, intrinsic FABs of health care providers can impact thecontent of medical encounters with patients with back pain-with direct consequences on patients’ outcomes [53–55].Health care providers with the strongest FABs are morelikely to recommend avoidance of activity and work andprescribe passive treatments, such as bed rest, with a resul-tant higher FAB and disability of their patients [51,53,56–58]. Of equal importance, health care providers with lowFAB are more likely to recommend continuation of activi-ties and work along with more active treatments to patientswith back pain [30]. Patients treated by these providers areobserved to lessen their FABs, and this strongly correlateswith improvements in their disability [23,59].

Despite evidence that health care providers’ FABs impactthe health of their patients, little is known about effectivestrategies to alter these beliefs. Latimer et al. [60] reportedon an educational project designed to change FABs of phys-ical therapy students. The results of this study indicated thatsubstantial changes in favor of endorsing function occurredafter a teaching module, and these changes were maintainedafter 1 year. Impact of these chanced beliefs on subsequentclinical outcomes for patients treated by these physical ther-apists was not documented, however.

Clinical assessment and classification of FABs

In order for FAB to be a useful construct, cliniciansshould be able to assess patients for unusually heightened

and therefore detrimental FAB during a typical medical en-counter, and this information must be useful for understand-ing the patient’s predicament. Although questionnaires havebeen developed that quantify FAB [11,61,62], their use israre outside research. However, during typical medical en-counters, most patients with low back pain express concernsabout the appropriateness of work and activities [63]. Theseconcerns are a reflection of FAB, and when they surface,health care providers who tactfully inquire about the sourcesof these concerns will find that rendered answers are quiterevealing.

Recently, experts have proposed that problematic FABmay be classified into three categories based on the emotionsand beliefs that patients use to explain their activity avoid-ance. These categories are misinformed avoiders, learnedavoiders, and affective avoiders [64]. Acknowledging thatbeliefs and emotions are frequently a continuum, these cate-gories offer sufficient face validity to be practical for offeringclinicians insight into the dimensions of FAB, with implica-tions about interventions (Tables 1 and 2).

It is probable that most patients with problematic FABsare misinformed avoiders. Based on the understanding oftheir predicament, these patients believe that certain move-ment and activities are likely to cause reinjury and furtherpain and therefore consciously choose to avoid those activi-ties. When asked, misinformed avoiders may report that it iscommon wisdom to avoid painful or strenuous back activi-ties or that they were given explicit instruction during priormedical encounters to avoid certain activities because oftheir potential for producing pain or harm. As patients, mis-informed avoiders may be hypervigilant but are generallyneither overly distressed nor necessarily report low self-efficacy or profound levels of disability. Of greatest impor-tance, their beliefs encompass ongoing reasoning and aretherefore amenable to change in response to new informationand new experiences.

Learned pain avoiders are a second group with problem-atic FAB. Learning theory suggests that avoidance behaviorscan be acquired without awareness simply through a Pavlov-ian association between making certain movements and ex-periencing pain. When asked, these patients express neitherelevated affect (fear of injury/reinjury) nor explicit beliefsabout the risk of injury from physical exposures. Instead,they view activities as painful and therefore choose to avoidthose activities simply to avoid pain. Theoretically, thelearned pain avoidance subgroups would require a differentemphasis in treatment as misinformation is not the basis fortheir disability.

Affective avoiders are the most challenging patientswith problematic FAB. These patients present as pro-foundly distressed about their back pain, exhibit excessivepain inhibitions during physical examination, and arestrongly committed to their disabilities. For these patients,the ability of physical activities to induce back pain has pro-duced a persistent irrational fear of physical activities. Af-fective avoiders often distort explanations and magnify

Table 1

Characteristics of subclassification of patients with problematic fear-avoidance beliefs

Element Misinformed avoiders Learned pain avoiders Affective avoiders

Emotions Discouraged Discouraged Fearful and highly distressed

Beliefs Pain indicates harm, and the spine is

vulnerable

Pain is benign; spine is sound; and pain

should be avoided

Distorted significance of pain and concerns

about conditions of the spine

Basis of beliefs Past experiences with back pain.

Information from multiple sources

Inherent value of pain versus function Emotionally charged misinterpretation of

past experiences and distortion of

medical information

Behaviors Hypervigilant but usually willing to

perform painful activities in a limited way

Choose to stop activities when they are

painful

Profound pain inhibition for movements.

Will not attempt activities that might

induce pain

Disability Mild to moderate Mild to moderate Severe

Comorbidities Uncommon Uncommon Catastrophizing, anxiety, depression,

concurrent musculoskeletal complaints

Treatment Information and experiences (exercise)

that challenge beliefs about the

importance of pain and restore

confidence in the spine

Unknown. (Exercises that desensitize the

pain response to physical stimuli might

be considered)

Address dysfunctional cognitions and

catastrophic thinking. Disconfirm fears

through gradual exposure to feared

activities

899J. Rainville et al. / The Spine Journal 11 (2011) 895–903

precautions given by health care providers to the point thatthey are adamant that certain activities are high risk for ru-inous back injuries. These challenging patients often pos-sess generalized negative affectivity toward all pain [32],pain hypervigilance [65], and catastrophic thinking [34].Many have important comorbidities, such as anxiety disor-der [66], depression [67], and concurrent chronic musculo-skeletal complaints [68]. Affective avoiders benefit fromtreatments that address dysfunctional cognitions and cata-strophic thinking and are minimally responsive to treat-ments if these areas are not addressed.

Methods for altering problematic FABs

FAB-reducing education directed at misinformedavoiders

For misinformed avoiders, the FAB that underlies theheightened concerns about low back pain must be continu-ously reconciled as new informations or experiences occurthat contradict their concerns. Educational interventionstake advantage of this process by present explanations for

Table 2

Summary of information and advice that may be useful for reducing fear-avoida

Information

Spine degeneration is a normal part of aging, with its onset and progression

largely determined by genetic factors

Physical activities are only minor contributors to spine degeneration

Low back pain results from a relatively benign process that includes

a combination of spine degeneration, local inflammation, reaction of

paraspinal muscles, and cognition

Chronic low back pain represents altered pain processing by the central

nervous system that results in pain hypersensitivity in which low back

pain can be evoked by innocuous normal stimulations of the spine and

adjacent tissues and therefore lacks protective function

low back pain that redirect patients’ concerns and restoringconfidence that the back, although painful, is strong andhealthy.

The use of FAB-reducing information to improve disabil-ity was first reported by Indahl et al. [69]. Randomly selectedsubjects with disabling low back pain met with a recognizedspine expert who explained that low back pain resulted froman uncomfortable but relatively benign process that includeda combination of spinal degeneration, local inflammation,reaction of paraspinal muscles, and cognition. This was fol-lowed by direct advice that loads on the spine normally donot cause lasting damage despite occasionally precipitatingpain, reduced focus on the pain (worry) might facilitate morenatural and less painfulmovements, it is beneficial to respondto back pain by stretching and light physical activities, andback pain benefited from remaining physically active. Whencompared with control group that received standard commu-nity care, the intervention group had half the number of sub-jects on sick leave over the next 5 years [70].

Multiple subsequent studies have assessed the effective-ness of FAB-reducing information, sometimes combinedwith exercise (often termed cognitive behavioral therapy),

nce beliefs

Advice

Altering physical activities does not prevent future degeneration

It is safe to load the spine as it normally does not cause lasting damage

despite occasionally precipitating pain

Back pain benefited from remaining physically active, and it is

advantageous to respond to back pain by stretching and light physical

activities

Chronic low back pain improves when pain hypersensitivity normalizes.

This might result from a gradual desensitization through graded

exposure to activities, along with reduced focus on the pain (worry) that

might facilitate more natural and less painful movements

900 J. Rainville et al. / The Spine Journal 11 (2011) 895–903

on low back pain outcomes. Most studies have used groupformats for presenting information, and results have dem-onstrated these treatment-improved outcomes comparedwith usual spine care plus a back brochure [71,72], routinephysical therapy [73], and a carefully constructed physicaltherapy paradigm [50]. Less robust differences betweentreatment arms were noted in a well-designed and executedstudy comparing education with active physical therapy, orboth treatments combined, as similar improvements werenoted in all groups [74]. One randomized trial comparedFAB-reducing information plus exercise with lumbar spinefusion for the treatment of chronic low back pain [47].The results revealed that both spine fusion and informationwith exercise have similar outcomes in terms of disabilityreduction but through markedly different mechanisms.For the spine fusion group, disability reduction mirroredoverall improvements in pain, whereas for the informationplus exercise, disability reduction paralleled lessening ofFAB.

Attempts have been made to deliver FAB-reducinginformation using simpler methods of communication.Burton et al. [75] developed The Back Book to conveythe messages that back pain is rarely a sign of serious dis-ease, and remaining active and moving were useful meansof hastening recovery. The effectiveness of The Back Bookwas assessed against a traditional booklet that insteadendorsed the importance of pain and recommended thatpainful activities be avoided. Results were mixed. Fear-avoidance belief was reduced in The Back Book groupbut unchanged in the control group. However, these differ-ences in FAB disappeared by 12 months and did not trans-late into reduced disability. In a separate study thatattempted to accomplish the same goal with videotapes,neither changes in FAB were noted nor evidence that thevideotapes transferred any knowledge to patients wasfound [76]. Additionally, presenting FAB-reducing infor-mation combined with advice to exercise in a primary caresetting did not improve outcomes compared with usualcare [77].

Several studies have used mass media to deliver FAB-reducing information as researchers postulated that lessen-ing FAB in the general population may be an effective wayto decrease the societal impact of low back pain. The firstattempt was undertaken by Buchbinder et al. [31] and useddozens of imaginative television commercials that con-veyed spine degeneration and back pain as benign normalprocesses, discouraged rest, and promoted exercise andcontinuation of work and daily activity during back painepisodes. Results demonstrated a small positive shift ofFAB within the study populations that was associated withsubstantial lessening of back pain–related disability claimswithin the targeted population. These results inspired addi-tional media campaigns in Scotland [78], Norway [79], andCanada [80]. These projects chose print and radio insteadof television to distribute the message, mainly to controlcost. Unfortunately, none of these campaigns demonstrated

a robust change in FAB or improvements in disability com-pensation. This has led to conclusions that successful me-dia campaigns probably require extensive media coverage(and therefore substantial financial resources) and shouldinclude explicit messages about the importance of workand the risk of overmedicalization of low back pain [80].These results suggest that FAB-reducing education mate-rials alone may be of limited value unless validated byrecognized source of spine expertise and delivered in com-pelling formats.

Interventions for learned pain avoiders

Learned pain avoiders are inherently different than mis-informed avoiders as they readily acknowledge that activi-ties are not harmful but choose to avoid them because theyare painful. To our knowledge, treatment strategies thatwould benefit learned pain avoiders have not been ex-plored. One approach that might have merit, however, isquota-based exercise as limited results suggest that backpain induced by physical exposures may be substantiallyreduced by systematically repeated exposure to those activ-ities in a tolerable way [81]. The neurological mechanismfor this pain desensitization remains unexplained.

Interventions for affective avoiders

Excessive fears and negative cognitions dominate thereactions of the affective avoiders resulting in a troublinggroup of people with entrenched disabling low back pain.Interventions for these patients would best systematicallychallenge irrational beliefs and behaviors. One suchapproach uses technique developed for addressing phobiascalled exposure in vivo [82]. This treatment selected anindividually tailored hierarchy of feared physical activitiesand gradually exposed patients to these activities, withthe goal to challenge catastrophic expectations and discon-firmed fears. The results of a trial of this treatment demon-strated that exposure in vivo was superior to gradedexercise as a means of reducing excessive FAB and paincatastrophizing but equal to graded exercise in reducingdisability [82,83].

Functional restoration is another treatment that targetsaffective avoiders. It integrates quota-based exercise de-signed to restore confidence that the spine is robust andcapable of normal physical and occupational activitieswhile simultaneously offering counseling directed at extin-guishing the negative perceptions and entitlements thatfoster disability [84]. Large case series have documentedthe utility of this approach for returning patients to work[84–86], and in randomized trials, functional restorationhas generally shown modest improvements in days lostfrom work [87]. As expected, functional restorationreduces FAB [23,88].

901J. Rainville et al. / The Spine Journal 11 (2011) 895–903

Summary

The current state of knowledge about FAB confirmstheir importance as factors influencing disability causedby low back pain. Growing evidence also suggests thatFABs can be affected during medical encounters and aretherefore justifiable targets of interventions. Realistically,however, translation of these advances into the routine careof low back pain will require substantial additional work,with many areas in need of additional study.

It would be useful to clarify the relationship betweenspecific theories of causation of low back pain and subse-quent FAB in different groups, including health care pro-viders, patients with low back pain, and the generalpublic. If data confirm that some theories such as the ‘‘cu-mulative injury model’’ of low back pain heighten disabil-ity, exploration of the value of displacing those theorieswould be useful.

To aid with the assessment of addressing FAB in clinicalpractice, evaluating the usefulness of classification of FABinto subgroups of misinformed, learner, and affectiveavoiders should be undertaken. This could be combinedwith the development and validation of clinical tools thatassess patients’ misinformation or misconceptions aboutlow back pain that reveal the areas in need of corrective ed-ucation. Conceivably, this might include the developmentof a short battery of key questions that could be adminis-tered during the medical history, such as those used to iden-tify problematic use of alcohol [89].

In the area of treatment, much could be gained from furtherstudies. It would be useful to assess the relative contributionsof subcomponents of the information conveyed through edu-cational interventions for lessening FAB. By doing so, thescope of information that it is essential to discuss with patientsmight be pared down to a brief intervention that could beadministered within the time constraints of typical medicalencounters. Studies of the value of supportive written or videomaterials for reinforcing information delivered by health careproviders during brief clinical encounters would also haveconsiderable worth. The utility of therapeutic exercise forlessening FAB deserves further study, both in terms of its ad-ditive value to information consistent with cognitive behav-ioral therapy and as a stand-alone treatment. As heightenedFABs tend to persist after interventions that are focused onpain reduction [47–50], clinical studies assessing the addedvalue of supplementary treatment that concurrently addressesFABs might be useful. Of course, cost-effectiveness of treat-ments that target FAB must be evaluated, especially as pres-sures to contain medical expenditures are mounting.

Finally, within the general patient populations, it would beuseful to further illuminate associations between minor dif-ferences in FABs and costs for medical care and disabilitycompensation for low back pain. If these are as large as sug-gested by the population-based study by Buchbinder et al.[31], it would seem prudent to invest in strategies to lessenFABs within populations.

Acknowledgments

The authors thank Dr Pradeep Suri, Dr Craig Brigham,andMark Schoene for their thoughtful reviews of this article.

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