Review article (meta-analysis)| Volume 99, ISSUE 11, P2287-2298, November 2018

Evaluation of Cognitive Behavioral Interventions and Psychoeducation Implemented by Rehabilitation Specialists to Treat Fear-Avoidance Beliefs in Patients With Low Back Pain: A Systematic Review

Published:December 13, 2017DOI:



      To systematically locate, critically appraise, and synthesize the available evidence regarding the effectiveness of cognitive behavioral therapies (CBTs) and psychoeducation that can be implemented by rehabilitation specialists to treat fear-avoidance beliefs in patients with acute, subacute, and chronic low back pain (LBP).

      Data Sources

      Electronic databases (CINAHL, PubMed, Psychology and Behavior Sciences Collection, SPORTDiscus, PsycINFO) were searched from inception to September 2017.

      Study Selection

      Assessment of methodological quality was completed using the Physiotherapy Evidence Database (PEDro) scale. The Strength of Recommendation Taxonomy was used to evaluate the quality of evidence.

      Data Extraction

      Study sample, subject demographics, CBT and/or psychoeducation intervention details, data collection time points, outcome assessments, statistical analysis, results, and conclusions were extracted from each study. In addition, effect sizes were calculated.

      Data Synthesis

      Five high-quality studies (PEDro ≥6) were included. All included studies evaluated fear-avoidance beliefs. CBTs and psychoeducation strategies designed to target patient-specific fears demonstrated clinically meaningful results, while psychoeducation methodologies were not as effective.


      There is inconsistent, patient-oriented evidence (grade B) to support the use of CBTs and/or psychoeducation strategies by rehabilitation specialists to treat fear-avoidance beliefs. Patient-centered and personalized CBTs were most effective to treat these psychosocial factors in patients with LBP when compared with a control treatment.


      List of abbreviations:

      CBT (cognitive behavioral therapy), CFT (cognitive functional therapy), FABQ (Fear-Avoidance Beliefs Questionnaire), FABQ-PA (Fear-Avoidance Beliefs Questionnaire–Physical Activity Subscale), FABQ-W (Fear-Avoidance Beliefs Questionnaire–Work Subscale), HSCL (Hopkins Symptom Checklist), LBP (low back pain), ODI (Oswestry Disability Index), PEDro (Physiotherapy Evidence Database), PINRS (Pain Intensity Numerical Rating Scale)
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