Fear-Avoidance Behavior and Anticipation of Pain in Patients With Chronic Low Back Pain: A Randomized Controlled Study

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Abstract
In a randomized controlled study, we investigated whether pain anticipation and fear-avoidance beliefs will lead to behavioral avoidance. Fifty patients with chronic low back pain (CLBP) performed a simple leg-flexion task. Before the test, members of a control group were informed that the movement would not result in any increase of pain, whereas experimental group participants were told that a slight increase of pain could occur. All patients completed the Fear-Avoidance-Beliefs Questionnaire (FABQ) and the Pain Disability Index (PDI). As dependent variables, different behavioral performance parameters were registered by a computerized protocol: number of flexion movements, mean range of motion, and mean work ratio. Furthermore, patients were asked about their pain intensity as well as their fear (at the moment) and finally were asked to judge the unpleasantness of the experiment (using visual analogue scales for each of the three variables). Inducing pain anticipation (by instruction) led to significantly lower levels of behavioral performance as well as increased pain intensity and fear during the test. Behavioral performance was significantly correlated with fear-avoidance beliefs. Results confirm that pain anticipation and fear-avoidance beliefs significantly influence the behavior of patients with low back pain in that they motivate avoidance behavior. Therapists must be aware of the powerful effects of cognitive processes, which can give rise to fear of pain and, consequently, avoidance behavior.