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Fear Avoidance Belief Questionnaire

Original Editor - Gina Gibson and Katie Werrick

Top Contributors - Vidya Acharya, Lucinda hampton, Anthonia Abraham, Jorge Rodríguez Palomino and Ewa Jaraczewska  

Objective

The Fear-Avoidance Beliefs Questionnaire (FABQ) is a patient reported questionnaire which specifically focuses on how a patient's fear avoidance beliefs about physical activity and work may affect and contribute to their chronic low back pain and resulting disability.

Description

Emergence of the biopsychosocial mode of low back pain (LBP) led to the development of the the Fear-Avoidance Beliefs Questionnaire (FABQ) by Waddel et al in 1993[1]. The FABQ is a questionnaire based on the Fear-Avoidance Model of Exaggerated Pain Perception, a model created in attempts to explain why some patients with acute painful conditions can recover while other patients develop chronic pain from such conditions[2][3][4]. The FABQ measures patients’ fear of pain and consequent avoidance of physical activity because of their fear[2][3]. It was specifically for use with patients with chronic low back pain, but it has since been adapted for use with other populations, such as people with spinal injuries, musculoskeletal conditions, and chronic pain.[2]

Areas of assessment include; ADLs, behaviour, functional mobility, general health, life participation, mental health, motivation, occupational performance, pain, personality, quality of life, self-efficacy, stress and coping.

Intended Population

The FABQ has been proven to be a reliable and valid assessment tool based on patients with chronic low back pain, and it has been shown to be predictive of pain intensity, disability, and quality of life. The FABQ can be used in a variety of settings, including:

  • Clinical practice: The FABQ can be used by clinicians to assess patients' fear-avoidance beliefs and to develop treatment plans accordingly. It is also used in patients with spinal injuries, musculoskeletal conditions and chronic pain.
  • Research: The FABQ can be used in research studies to investigate the relationship between fear-avoidance beliefs and other factors, such as pain, disability, and quality of life. In recent research, the FABQ is being used in populations with acute low back pain to identify the risk of long-term disability[3]
  • Workplace: The FABQ can be used in the workplace to identify employees who are at risk for developing chronic pain or who may be struggling to manage their pain.

Methods of Use

FABQ is a self-report questionnaire, meaning the person completes it independently. The questionnaire consists of 16 items in which a patient rates their agreement with each statement on a 7-point Likert scale. Where 0= completely disagree, 6=completely agree. The total score is calculated by summing the scores for all 16 items. There is a maximum score of 96. A higher score indicates more strongly held fear avoidance beliefs. [2]

There are two subscales within the FABQ;

  • Fear-avoidance beliefs about work (FABQw): This subscale measures the person's beliefs about how their work may affect their pain. It has 7 questions (maximum score of 42)[5]
  • Fear-avoidance beliefs about physical activity: This subscale measures the person's beliefs about how physical activity may affect their pain and has 4 questions (maximum score of 24) [2][3][5]. The numbers in parentheses below designate which items from the FABQ are included in each subscale[2].
     
Subscale Questions Included Total Possible Points High Score
FABQw 6,7,9-12, 15 42 >34[3]
FABQpa 2-5 24 >15[6]


The questionnaire takes approximately 10 minutes to complete.

A strong relationship exists between elevated fear avoidance beliefs and chronic disability secondary to LBP[2][3]. “Avoidance may lead to reduced activity levels, an exacerbation of the fear and avoidance behaviors, prolonged disability, and adverse physical and psychological effects” [3][4][7]. Thus, the FABQ is an outcome measure that serves as a clinically useful screening tool in identifying patients with high fear avoidance beliefs who are at risk for prolonged disability. Management of patients with elevated FABQ scores requires clinicians to tailor interventions to meet those needs. Research suggests multi-disciplinary approach including cognitive behavioral therapy and graded exposure to physical activity[3].

Scoring the FABQ

The total score for the FABQ is calculated by summing the scores for all 16 items. A higher score indicates higher levels of fear-avoidance beliefs.[8]

The following table shows the interpretation of FABQ scores:

Score Interpretation
0-48 Low levels of fear-avoidance beliefs
49-64 Moderate levels of fear-avoidance beliefs
65-96 High levels of fear-avoidance beliefs

Clinical Implications

Fear-avoidance beliefs are a known risk factor for developing chronic pain and disability. Therefore, it is important to identify and address fear-avoidance beliefs in people with pain.[9]

Several treatments can address fear-avoidance beliefs, such as cognitive-behavioural therapy, exposure therapy, and graded activity therapy.

If you are concerned that you may have high fear-avoidance beliefs, it is important to talk to your doctor or physical therapist.[10] They can help you to assess your fear-avoidance beliefs and to develop a treatment plan to address them.

Evidence

Reliability

  • Total FABQ test-retest reliability (ICC=0.97)[6]
  • FABQ Physical Activity subscale test-retest reliability (ICC=0.72-0.90)[6]
  • FABQ Work subscale test-retest reliability (ICC=0.80-0.91)[6]
  • The use of the FAbQ as a screening tool for patients with non-work related LBP was not supported[11]
  • The FABQ (When 'back' is replaced by 'shoulder') is an adequate predictor of how fear avoidance behaviours contribute to shoulder pain and disability. [12]
  • The FABQ may be recommended for test-retest evaluations as 'good' reliability was found, and it has the ability to discriminate between patients with cervical radiculopathy and healthy subjects. [13]

Validity

  • Evidence shows that the FABQ is correlated with Roland and Morris Disability Questionnaire. The correlation coefficients for the FABQ, the FABQ Work subscale and the FABQ Physical Activity subscale are 0.52, 0.63, and 0.51, respectively.[6]
  • The FABQ was also shown to be correlated with the Tampa Scale of Kinesiophobia, another measure of fear avoidance. The correlation coefficients for the FABQ Work subscale and the FABQ Physical Activity subscale are 0.53 and 0.76, respectively.[6]
  • The FABQ is not a good indicator of mental health for patients with pelvic girdle pain and has questionable validity when assessing these patients. [14]

Resources

Fear-Avoidance Beliefs Questionnaire 

References

  1. ↑ Waddell et al (1993) Pain 52: 157–168.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Waddell C, 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
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Fritz JM, George S. Identifying Psychosocial Variables in Patients With Acute Work-Related Low Back Pain: The Importance of Fear-Avoidance Beliefs. Phys Ther. 2002; 82(10): 973-983.
  4. ↑ 4.0 4.1 Lethem J, Slade PD, Troup JDG, Bendey G. Outline of a fear avoidance model of exaggerated pain perceptions, Behav Res Ther. 1983;21:401-408.
  5. ↑ 5.0 5.1 Gatchel, R. J., & Turk, D. C. (2002). Psychosocial factors in chronic pain: Critical review and implications for treatment. Psychological Bulletin, 128(4), 573.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Williamson E. Fear Avoidance Behavior Questionnaire. Austrailian Journal of Physiotherapy. 2006; 52: 149.
  7. ↑ Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eck H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62: 36, 272.
  8. ↑ Crombez, G., Vlaeyen, J. W., & Lysens, R. (1999). Pain-related fear and avoidance: A review of the literature. Clinical psychology review, 19(7), 1059-1076.
  9. ↑ Van Oosterwijck, J., Meeus, M., De Clercq, D., & Nijs, J. (2010). The FABQ: A systematic review on its psychometric properties. Pain, 149(3), 434-444.
  10. ↑ Wideman, T. H., Scott, W., Martel, M. O., & Sullivan, M. J. L. (2012). Recovery from chronic pain: A biopsychosocial perspective. Journal of pain, 13(3), S2-S11.
  11. ↑ Cleland, Joshua A, Fritz, Julie M, & Brennan, Gerard P. (2008). Predictive validity of initial fear avoidance beliefs in patients with low back pain receiving physical therapy: is the FABQ a useful screening tool for identifying patients at risk for a poor recovery? European Spine Journal, 17(1), 70-79.
  12. ↑ Mintken, Paul E, Cleland, Joshua A, Whitman, Julie M, & George, Steven Z. (2010). Psychometric properties of the Fear-Avoidance Beliefs Questionnaire and Tampa Scale of Kinesiophobia in patients with shoulder pain. Archives of physical medicine and rehabilitation, 91(7), 1128-1136. 
  13. ↑ Dedering, Åsa, & Börjesson, Tina. (2013). Assessing Fear‐avoidance Beliefs in Patients with Cervical Radiculopathy. Physiotherapy Research International, 18(4), 193-202.
  14. ↑ Grotle, Margreth, Garratt, Andrew M, Jenssen, Hanne Krogstad, & Stuge, Britt. (2012). Reliability and construct validity of self-report questionnaires for patients with pelvic girdle pain. Physical therapy, 92(1), 111-123. 
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