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The Effect of a Fear-Avoidance–Based Physical Therapy Intervention for Patients With Acute Low Back Pain: Results of a Randomized Clinical Trial

George, Steven Z., PT, PhD*; Fritz, Julie M., PT, PhD, ATC; Bialosky, Joel E., PT, MS; Donald, Douglas A., MPT§

doi: 10.1097/01.BRS.0000096677.84605.A2
Randomized Trial

Study Design.  A randomized clinical trial with 4-week and 6-month follow-up periods.

Objective.  To compare the effect of a fear-avoidance–based physical therapy intervention with standard care physical therapy for patients with acute low back pain.

Summary of Background Data.  The disability reduction strategy of secondary prevention involves providing specific treatment for patients that are likely to have chronic disability from low back pain. Previous studies have indicated that elevated fear-avoidance beliefs are a precursor to chronic disability from low back pain. However, the effectiveness of physical therapy intervention based on a fear-avoidance model is unknown.

Methods.  Sixty-six consecutive patients referred to physical therapy with low back pain of less than 8 weeks’ duration were randomly assigned to receive fear-avoidance–based physical therapy (n = 34) or standard care physical therapy (n = 32). The intervention period lasted 4 weeks for this study. Disability, pain intensity, and fear-avoidance beliefs measures were recorded before and after treatment. A 6-month follow-up of the same measures was obtained by mail.

Results.  An intention-to-treat principle (last value forward) was used for data analyses that tested the primary and secondary hypotheses. The prediction of disability at 4 weeks and 6 months after treatment was significantly improved by considering the interaction between the type of treatment and the initial level of fear-avoidance beliefs. Both groups had significant within group improvements for disability and pain intensity. The fear-avoidance treatment group had a significant improvement in fear-avoidance beliefs, and fear-avoidance beliefs about physical activity were significantly lower than the standard care group at 4 weeks and 6 months after treatment.

Conclusion.  Patients with elevated fear-avoidance beliefs appeared to have less disability from fear-avoidance–based physical therapy when compared to those receiving standard care physical therapy. Patients with lower fear-avoidance beliefs appeared to have more disability from fear-avoidance–based physical therapy, when compared to those receiving standard care physical therapy. In addition, physical therapy supplemented with fear-avoidance–based principles contributed to a positive shift in fear-avoidance beliefs.

From the *Center for Pain Research and Treatment, Brooks Center for Rehabilitation Studies, University of Florida, Gainsville, Florida,

†Department of Physical Therapy and the

‡Veterans Affairs Medical Center, University of Pittsburgh, Pittsburgh, and

§NovaCare Rehabilitation, Pittsburgh, Pennsylvania.

Support for this study was provided by the Foundation for Physical Therapy.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Foundation funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

Address correspondence to Steven Z. George PT, PhD, Post Doctoral Research Fellow, Center for Pain Research and Behavioral Health, Brooks Center for Rehabilitation Studies, P.O. Box 100165, Health Sciences Center, University of Florida, Gainesville, FL 32610-0165, USA; E-mail:

© 2003 Lippincott Williams & Wilkins, Inc.