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The Fear-avoidance Components Scale (FACS): Development and Psychometric Evaluation of a New Measure of Pain-related Fear Avoidance. Neblett et al. 2016
In the cervical weekend course a few weeks ago we briefly touched on patient fear avoidance (FA) and the tools we use to measure this construct. Currently there are several which are commonly used, including the Pain Catastrophizing Scale (PCS), Fear Avoidance Beliefs Questionnaire (FABQ), and Tampa Scale of Kinesiophobia (TSK). This article looks at a new metric for measuring FA in our patients.
The article begins by highlighting the fact that all of the above measures were developed before the FA model was completed, and do not fully measure the domains of fear avoidance, including fear of pain, fear of injury, and avoidance of movement due to pain. The purpose of this study was to create a new patient reported outcome (PRO) to more fully measure FA.
Without providing all of the study details, some components from each section do stand out. The measure was developed by assessing the current cognitive, affective, and behavioral components of the FA model. The developers then drew from current PRO measures and added items from the Injustice Experience Questionnaire. The authors made a point of including questions on specific activities so that clinicians could better target the activities that patients found most problematic.
For the psychometric evaluation the authors looked at individuals with chronic musculoskeletal pain disorder (CMPD) (n=419), chronic pain patients receiving psychiatric treatment (n=282) and individuals with a current painful medical condition not seeking treatment (n=87). CMPD patients completed a squat lift at a light weight (3lbs) in addition to a battery of the current FA PROs, BDI, and Insomnia Severity scale.
The researches found a high test-retest reliability in the CMPD population, as well as a high internal consistency. Severity scales were developed to assist with clinical assessment, and scores were compared with patients ability to complete the squat lift.
There are several things about this outcome measure which I think are promising. First, I like that the authors gathered data on patient feedback regarding the ease of use of the questionnaire, because at the end of the day it needs to be something people will actually fill out. Including a component of victim blaming/alienation in the initial development was important, as in my experience this can be such a large piece of fear avoidance, especially for individuals trying to return to work. One of the most important pieces of this new PRO is the development of cutoff scores that can be used to guide clinical decision making. Currently something like Wideman’s Cumulative Psychological Factor Index can be used, but this can be time consuming, and the standard of FABQ-W has never been ideal for return to work screening/referral. Although the FACS will need a lot more work for this use, I think this article was a good starting point. The biggest weakness of this study is, as the authors point out, the generalizability of the CMPD population data to other populations that we frequently see.
Some questions that I’d like to hear everyone’s thoughts on:
1) What measures of FA have you used most frequently in your clinic now or in the past? What do you like or not like about particular PROs? What are your thoughts on this metric for use in the clinic? Possible positives and negatives of its use?
2) When you do have a patient, potentially one who is trying to return to work, that responds with a high score on one of these outcome measures, to what extent do you address their fear avoidance? Has anyone utilized true graded exposure or graded activity training to address fear avoidance? Or has your approach been more informal and education based?
3) Similarly, when you do have a patient with high FA, what sorts of resources have you used to refer patients to other providers? -
Nice post August. I like the idea and what they are attempting to do with the questionnaire, but I don’t like the name because what they are doing is so much more than looking at fear avoidance.
All patients with chronic pain do not avoid movement. With regards to patients with chronic pain, what we do want to know as clinicians in addition to whether they avoid movement are; 1. what their perception of pain is (ie all pain is bad), 2. are they hypervigilent about it,3. how is that impacting their lives both physically and emotionally, 4. whether they think this can improve or not. This PRO is attempting to identify these variables, and that’s why I’m a bit perplexed in the name selection.
In response to some of your questions; if a patient of mine has fear of movement I always address it. How and when I address it changes from patient to patient. Some patients are receptive and some are not. Just like all techniques, the more I worked at it the better I got at it, and the more patients understand what I am getting at (analogies work the best).
I will utilize graded exposure for patients who avoid specific movements due to fear of that one movement. I will use graded exercise for patients who view all movement as painful. The design of these approaches rely on goal setting and sticking to these goals. This has worked well for my patients in the past. -
Interesting article August. It will be interesting to see future research on this and when it starts popping up in other articles as an outcome measure as the FABQ has.
In my limited clinical experience I have only had a few patients that were truly fear avoidant. I have primarily used educational interventions thus far, and realized I am not that good at it yet. As of recent I have had a few low back patients I have been successful with. I used educational analogies using other joints as examples.
One in particular I have been using is Peter O’Sullivan’s wrist example. Explaining that if I made a fist all day trying to protect my wrist joint, bending and moving it would be painful (then I have them try it). Additionally, my ROM would decrease because my muscles are preventing it from achieving end range, leading to decreased joint mobility. The back is no different, just think of it as a bunch of little wrist joints. If you guard it by tightening your core with every movement, it might be a little uncomfortable just as the wrist is when you move it while maintaining a fist. It doesn’t mean something is being damaged, just that you muscles are trying to protect the spine and they don’t have to. Just as relaxing your fist made your wrist feel better and move better, so can your back…This has been somewhat successful for me for 2 patients in particular this past week. But I have to continue to work on my ability to educate patients that are fear avoidant.
In regards to graded graded exposure and graded activity, I have not used either in the clinic yet. I had a patient this week that indirectly reminded me of the importance of this and its effectiveness. She was involved in an MVA and verbalized to me that she is still terrified when driving her car. She told me that she has planned several 10 minute drives during her days to re-establish a sense of safety when driving. Just as she has created graded exposure goals for herself in regards to driving, we should to the same with patients who fear certain movements. If the pt fears vacuuming their house due to the pain it causes, we should set goals, as AJ has mentioned, to start with vacuuming their living room this week. Next week, vacuum the living room and bedroom…And so one. Like I said, I have not used this in the clinic yet but I will try to use them the way AJ has mentioned he has found beneficial.
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This outcome measure shows a great deal of promise for use with patient’s that show signs of FA and chronic pain behavior. August brings up a good point that the cutoff score will help in determining how to progress with patients. I look forward to seeing if and how these cutoffs vary with further studies using more diverse patient populations. Another aspect of this study that I really liked was the fact that it takes into account what the patient is fearful of. Understanding whether the patient is afraid of pain itself, increased pain, or (re)injury is extremely valuable when determining how to progress our treatments.
To answer August’s questions, the only FA measure I have any experience with is the FABQ. I think it works well for patients with LBP that want to return to work or are limited at work due to their pain, but that makes it a very narrowly useful measure. However, the FABQ is useful in this specific population due to the large body of research behind it.
I honestly have not used these measures recently with patients, but I have been using graded exposure for a couple patients that want to return to tennis. They both display signs of fear avoidance with exercises during Physical Therapy and have given themselves return to play times that far exceed what you would usually expect with their injuries. As they became more comfortable with the interventions used I started to work in jogging, agility drill, and rotational challenges that simulate swinging a racket. One has begun to hit balls with a machine while the other has still been avoiding beginning tennis drills. I have noticed with the graded exposure approach both patients have hit a plateau at different levels of recovery and I have begun to incorporate more educational for these patients. It has been helpful for these patients to make them aware of the kinds of movements they are capable of during Physical Therapy Intervention and relating that to tennis or whatever activity is causing their pain. One of the patients has begun to realize that what we do in therapy is practically as challenging or more challenging than what they are doing on their own. This has increased his confidence for returning to full play, however we still have not gone there quite yet. I have not yet had a patient that I thought may need a referral to another provider, but I look forward to hearing what others have to say about this.
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Great article, Austin. I too am interested to see future research on this and how it will affect patient care clinically. I can relate to you, Justin, in that in my limited clinical experience I have not had many patients who are truly fear avoidant. In some cases where I believe someone may benefit from addressing some degree of being fearful of pain or movement, I have used more of an informational and education-based approach. I found reading Adriaan Louw’s book, Why Do I Hurt?, while directed more towards the patient population and not health care professionals, helpful as it provided some great examples of analogies for hypervigilance of pain and the effects chronic pain can have. With fear avoidance in particular, I believe it maybe important to get to know your patients first in order to gauge how they will react to the information you are providing them. Additionally, I have seen with some patients, just getting them moving, no matter what their complaint is, has changed their perception of pain and movement.
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While I agree that true fear-avoidant dominant behavior is not seen that commonly in a typical OP practice, I think we commonly see altered behaviors and movement patterns, many of which persist unbeknownst to the patient. O’Sullivan made a distinction between adaptive and maladaptive behaviors. No different than using a crutch or a brace for a period of time, limping or having a lumbar shift may be necessary during the acute phase of an injury. However, this behavior and pattern may become maladaptive if maintained over a period of time. Identifying and discussing these patterns with patients can help with the overall education and alliance of your sessions. Pointing out to a patient that they sit with less weight through one side of their pelvis, or asymmetrical weight acceptance with transfer, etc., can be huge talking points and asking “why do you do that” will open a dialogue that often will assist your care. While these outcome measures give some meat to what we do, do not forget to assess and address the physical situation you observe as well.
#MakeOrthopedicsGreatAgain -
August,
I agree with your statement that these beliefs and feelings can lead to avoidant behavior. However, some have not reached that level yet, but its important to identify those who may get there. My concern would be that a PRO like this could get pigeon holed based on the name. Yes, I guess I would have chose something different (Pain beliefs or pain perception??). Just don’t know what that would be. I’m not that smart! -
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AJ – You succinctly laid out a really nice set of 5 questions we can ask to get the discussion rolling on pain, and whether we need to administer a specific fear avoidance scale. Did you get this from a specific framework/paper, or just through your experience? (1. Do you avoid movement 2. What their perception of pain is (ie all pain is bad), 3. Are they hypervigilant about it 4. how is that impacting their lives both physically and emotionally 5. whether they think this can improve or not.)
Justin – I love the wrist example. I’m stealing that immediately.
Katie – Great point about getting a good read on your patient before delving into biopsychosocial aspects of pain. Even when I feel like I have done a decent job of educating my patient, I have still gotten a response of “So, you’re saying it’s all in my head?”, which can be frustrating and decrease therapeutic alliance with the patient
Aaron – I like the idea of asking the patient “Why do you do that?”, as this makes them generate a hypothesis that you can work towards deconstructing. I think this is a better strategy than what most new grads do, which is that when we see something abnormal we immediately say “Oh, do you see that? you are shifted/asymmetrical with weight-bearing, etc” And then we put our own assumption as to why the person is actually doing that versus just asking them. Sometimes just saying something like “you are shifted” can make someone more fearful
For answers to your questions, Austin:
1) What measures of FA have you used most frequently in your clinic now or in the past? What do you like or not like about particular PROs? What are your thoughts on this metric for use in the clinic? Possible positives and negatives of its use?
Most often it’s the FABQ. I have used the Pain Catastrophizing Scale (PCS) and Tampa Scale of Kinesiophobia in the past. I actually hate using the PCS because of the name. I feel like sometimes a patient reads the name of the scale and thinks “Is he saying i’m being dramatic?”. I’d use it more if I could just black out the name. The FABQ is included in FOTO so the patient never sees the words “fear avoidance”.
2) When you do have a patient, potentially one who is trying to return to work, that responds with a high score on one of these outcome measures, to what extent do you address their fear avoidance? Has anyone utilized true graded exposure or graded activity training to address fear avoidance? Or has your approach been more informal and education based?.
I’m currently using graded activity with a chronic LBP and hip pain patient. It started with a lot of education (over at least 3-4 sessions) before she agreed to try it. She has been slowly decreasing her activity level and social activities for 15 years due to pain and avoidance. Allowing her to choose exercises where she can have initial success has been key in her buying into the treatment plan. In addition, when we perform treadmill training, giving her full control over when we stop the exercise really decreases her fear and is a useful strategy
3) Similarly, when you do have a patient with high FA, what sorts of resources have you used to refer patients to other providers?
During clinicals I had one or two patients where a psych referral was warranted and initiated. I have yet to initiate a psych referral while working at Progress. I currently have been co-treating a patient with body image issues that are starting to affect her function where one is warranted, but it hasn’t happened yet.
What other types of resources/referrals are you thinking about here, August?
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