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Finnish version of the fear-avoidance-beliefs questionnaire (FABQ) and the importance of validated questionnaires on FAB in clinical praxis and in research on low-back pain

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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 10 Issue 1

In this issue of the Scandinavian Journal of Pain, Terho and coworkers [1] report about the translation and validation of the Finnish version of the Fear-Avoidance Beliefs Questionnaire (FABQ). This questionnaire plays an important role in the diagnostic assessment of patients with low-back pain (LBP).

1 The importance of psychological aspects of chronic pain

Psychological factors have been proven to influence the development and clinical course of chronic LBP; especially cognitive and affective variables with behavioural consequences are relevant determinants of pain experience and disability in those patients [2]. A frequent assumption of patients with LBP is that activity will exacerbate pain and promote suffering, which may lead to an ongoing avoidance of activities in the future. The resulting avoidance behaviour may subsequently lead to negative consequences characterized by physical deconditioning, sick role behaviour, psy-chosocial withdrawal and negative affect corresponding to a high level of disability. According to cognitive-behavioural theory, this circle is maintained by the perceived reduction of anxiety, which is achieved through avoidance of feared activities. These mechanisms have been described in the fear-avoidance model of chronic pain [3] that is a major contribution to the understanding of the chronification process and maintenance of LBP.

2 Solid evidence for the importance of fear-avoidance beliefs in developing and persistence of chronic low-back pain

In a systematic review from 2007, several authors provided convincing evidence for the fear-avoidance model [4]. In that review already more than 200 studies were reviewed, this has been followed by a steady rise in publications on this topic up to now.

In two recent systematic reviews Wertli et al. from Switzerland [5,6] summarized the evidence examining the influence of fear avoidance beliefs (FAB) on both the development of low back pain [5] and treatment outcomes [6]. In patients with LBP of up to 6 months duration, high FABs were associated with more pain and/or disability and lower rates of return to work.

However, fear avoidance beliefs in very acute LBP (<2 weeks) and subacute LBP (>3 months) were mostly not predictive. A decrease in FABs values during treatment was associated with less pain and disability at follow-up. Interventions that also addressed FABs specifically were more effective than control groups based on biomedical concepts. Again, in chronic patients with LBP, these findings were less consistent. The authors concluded that early identification of FABs and early treatment, including interventions to reduce FABs, may prevent delayed recovery and chronicity. In addition, patients with high FABs are more likely to improve when FABs are addressed in treatments than when these beliefs are ignored, and treatment strategies should be modified if FABs are present.

Results of an expert panel held at the “Forum Primary Care Research on Low Back Pain”, during June 2009, at the Harvard School of Public Health in Boston, MA, USA were summarized by Rainville et al. [7]. Again, the clinical relevance of fear-avoidance was confirmed and strong evidence was found that excessive FABs result in heightened disability and are obstacles for recovery from acute, subacute, and chronic low back pain.

3 More knowledge of fear-avoidance beliefs in clinical practice obtained with the FABQ

On the other hand, the group identified several urgent needs for further studies and one of those needs is gathering more knowledge about brief methods for assessing FAB during clinical encounters. A practical tool to validly identify FAB could improve the ability of clinicians to assess those important characteristics of their patients, with the potential to provide information and education to reduce fears and encourage timely return to activity.

The two most commonly used questionnaires for that purpose are the Fear Avoidance Beliefs Questionnaire [8] and the Tampa Scale of Kinesiophobia (TSK) [9]. However, their usefulness for detecting fear avoidance beliefs that influence the transition from acute to chronic LBP is not clearly determined and has been critically debated in the literature. Interestingly, self-report measures (FABQ TSK, etc.) did not correspond to physical therapists’ rating of perceived patient fear-avoidance [10] and several measures of pain-related fear were not significantly correlated to physical capacity measurements [11].

4 FAB plays an important role in the course of low-back pain

This raises several questions and suggests the need for further studies: Do different instruments measure the same constructs? Is it necessary to reconceptualize the FAB-Model and put it in a broader framework of pain-related disability, as it was proposed recently [12]?

However, although there is still a lack of understanding of the precise mechanisms and a continuing scientific debate, we can be sure that FAB plays an important role in the course of back pain. Due to the strong burden of low-back pain in all industrialized countries, it is thus beneficial to have translated versions of already validated questionnaires to widen our understanding of FAB in differing social contexts.

5 The Finnish version of the FABQ has confirmed previous observations in Germany and Italy concerning beliefs about the work-place

Hence, this study of validating the FABQin the Finnish language by Terho and co-workers [1] is very welcome. The authors translated the FABQ and studied its psychometric properties among Finnish patients with chronic LBP. The Finnish version of the FABQdemonstrated good values for internal consistency and retest reliability. However, the authors also found interesting further results that do not correspond to the original version of the FABQ [8]. On the other hand, these different findings were in accordance with previous validation studies in Germany [13] and in Italy [14].

One consistent result in those three studies may be of further significance: While the original version of the FABQ consisted of two subscales - beliefs concerning activities and beliefs concerning work-place - Terho and co-workers [1] again identified a three-factor solution similar to the German and Italian versions.

This may suggest that the original subscale ‘work’ should optimally be divided into two work-related subscales describing different aspects of (1) thoughts about work and (2) thoughts about the work-place. The separate scoring on those two subscales seem to have considerable advantages in more precisely identifying problematic patientsbeliefs and attitudes concerning work and work-place than is possible from one work-subscale only.

There are indications, that especially beliefs concerning the work situation play an important role in ongoing pain and disability: The work-subscale of the FABQ was identified as a good predictor of self-report disability and the authors of that study suggested further testing and refining of that scale to better predict short-terms outcome in LBP [15]. In the review from Wertli et al. [5] the highest OR (4.64) for ongoing pain and disability was found when applying a high cutoff for the FABQ work-subscale scores. This especially is the strength of the FABQ in contrast to the TSK: the FABQ incorporates 10 items, which address work and work-place situation. From experience in Germany, we know that occupation and working-place play a major role in the development of low-back pain, disability, and resulting work absenteeism. These interrelations are still poorly understood and require further investigation. In view of these results, the factor structure of FABQ probably needs a thorough re-evaluation. There is a strong need for a practicable questionnaire to identify those beliefs in clinical praxis. This could best be conducted using a large patient sample from European countries, where a validated translation of the FABQ is available.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2015.09.003.

  1. Conflicts of interest: None declared.

References

[1] Terho H, Haapea M, Paananen M, Korniloff K, Häkkinen A, Karppinen J. Translation and validation of the Finnish version of the fear-avoidance beliefs questionnaire (FABQ). ScandJ Pain 2016;10:113–8.Search in Google Scholar

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Published Online: 2016-01-01
Published in Print: 2016-01-01

© 2015 Scandinavian Association for the Study of Pain

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  48. Translation and validation of the Finnish version of the Fear-Avoidance Beliefs Questionnaire (FABQ)
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https://doi.org/10.1016/j.sjpain.2015.11.002

Articles in the same Issue

  1. Editorial comment
  2. Plasma pro-inflammatory markers in chronic neuropathic pain: Why elevated levels may be relevant for diagnosis and treatment of patients suffering chronic pain
  3. Original experimental
  4. Plasma pro-inflammatory markers in chronic neuropathic pain: A multivariate, comparative, cross-sectional pilot study
  5. Editorial comment
  6. Genetic variability of pain – A patient focused end-point
  7. Observational study
  8. COMT and OPRM1 genotype associations with daily knee pain variability and activity induced pain
  9. Editorial comment
  10. Complex Regional Pain Syndrome (CRPS) after viper-bite in a pregnant young woman: Pathophysiology and treatment options
  11. Clinical pain research
  12. Complex regional pain syndrome following viper-bite
  13. Editorial comment
  14. An investigation into enlarging and reducing the size of mirror reflections of the hand on experimentally induced cold-pressor pain in healthy volunteers
  15. Original experimental
  16. An investigation into enlarging and reducing the size of mirror reflections of the hand on experimentally-induced cold-pressor pain in healthy human participants
  17. Editorial comment
  18. Multimodal Rehabilitation Programs (MMRP) for patients with longstanding complex pain conditions – The need for quality control with follow-up studies of patient outcomes
  19. Observational study
  20. Patients with chronic pain: One-year follow-up of a multimodal rehabilitation programme at a pain clinic
  21. Editorial comment
  22. Advancing methods for characterizing structure and functions of small nerve fibres in neuropathic conditions
  23. Clinical pain research
  24. Structural and functional characterization of nerve fibres in polyneuropathy and healthy subjects
  25. Editorial comment
  26. Stimulation-induced expression of immediate early gene proteins in the dorsal horn is increased in neuropathy
  27. Original experimental
  28. Stimulation-induced expression of immediate early gene proteins in the dorsal horn is increased in neuropathy
  29. Editorial comment
  30. Targeting glial dysfunction to treat post-surgical neuropathic pain
  31. Topical review
  32. Glial dysfunction and persistent neuropathic postsurgical pain
  33. Editorial comment
  34. Mechanisms of cognitive impairment in chronic pain patients can now be studied preclinically by inducing cognitive deficits with an experimental animal model of chronic neuropathic pain
  35. Original experimental
  36. Impaired recognition memory and cognitive flexibility in the ratL5–L6 spinal nerve ligation model of neuropathic pain
  37. Editorial comment
  38. Pain treatment with intrathecal corticosteroids: Much ado about nothing? But epidural corticosteroids for radicular pain is still an option
  39. Original experimental
  40. Analgesic properties of intrathecal glucocorticoids in three well established preclinical pain models
  41. Editorial comment
  42. The obesity epidemic makes life difficult for patients with herniated lumbar discs – and for back-surgeons: Increased risk of complications
  43. Observational study
  44. Obesity has an impact on outcome in lumbar disc surgery
  45. Editorial comment
  46. Finnish version of the fear-avoidance-beliefs questionnaire (FABQ) and the importance of validated questionnaires on FAB in clinical praxis and in research on low-back pain
  47. Clinical pain research
  48. Translation and validation of the Finnish version of the Fear-Avoidance Beliefs Questionnaire (FABQ)
  49. Editorial comment
  50. Pain, sleep and catastrophizing: The conceptualization matters Comment on Wilt JA et al. “A multilevel path model analysis of the relations between sleep, pain, and pain catastrophizing in chronic pain rehabilitation patients”
  51. Clinical pain research
  52. A multilevel path model analysis of the relations between sleep, pain, and pain catastrophizing in chronic pain rehabilitation patients
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