• Maria M Wertli, Eva Rasmussen-Barr, Sherri Weiser, Lucas M Bachmann, and Florian Brunner.
• Occupational and Industrial Orthopaedic Center (OIOC), NYU Hospital for Joint Diseases, New York University, 63 Downing St, New York, NY 10014, USA; Department of Internal Medicine, Horten Centre for Patient Oriented Research and Knowledge Transfer, University of Zurich, Pestalozzistrasse 24, 8032 Zurich, Switzerland. Electronic address: Maria.Wertli@usz.ch.
• Spine J. 2014 May 1;14(5):816-36.e4.

Background ContextPsychological factors including fear avoidance beliefs are believed to influence the development of chronic low back pain (LBP).PurposeThe purpose of this study was to determine the prognostic importance of fear avoidance beliefs as assessed by the Fear Avoidance Beliefs Questionnaire (FABQ) and the Tampa Scale of Kinesiophobia for clinically relevant outcomes in patients with nonspecific LBP.Design/SettingThe design of this study was a systematic review.MethodsIn October 2011, the following databases were searched: BIOSIS, CINAHL, Cochrane Library, Embase, OTSeeker, PeDRO, PsycInfo, PubMed/Medline, Scopus, and Web of Science. To ensure the completeness of the search, a hand search and a search of bibliographies was conducted and all relevant references included. A total of 2,031 references were retrieved, leaving 566 references after the removal of duplicates. For 53 references, the full-text was assessed and, finally, 21 studies were included in the analysis.ResultsThe most convincing evidence was found supporting fear avoidance beliefs to be a prognostic factor for work-related outcomes in patients with subacute LBP (ie, 4 weeks-3 months of LBP). Four cohort studies, conducted by disability insurance companies in the United States, Canada, and Belgium, included 258 to 1,068 patients mostly with nonspecific LBP. These researchers found an increased risk for work-related outcomes (not returning to work, sick days) with elevated FABQ scores. The odds ratio (OR) ranged from 1.05 (95% confidence interval [CI] 1.02-1.09) to 4.64 (95% CI, 1.57-13.71). The highest OR was found when applying a high cutoff for FABQ Work subscale scores. This may indicate that the use of cutoff values increases the likelihood of positive findings. This issue requires further study. Fear avoidance beliefs in very acute LBP (<2 weeks) and chronic LBP (>3 months) was mostly not predictive.ConclusionsEvidence suggests that fear avoidance beliefs are prognostic for poor outcome in subacute LBP, and thus early treatment, including interventions to reduce fear avoidance beliefs, may avoid delayed recovery and chronicity.Copyright © 2014 Elsevier Inc. All rights reserved.

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