The effect of evidence-based education modifications on fear-avoidance beliefs and pain catastrophizing for patients with low back pain

It has recently been suggested that patient education for low back pain (LBP) should include factual information that decreases fear and threat. Available evidence suggests this approach effectively reduces fear-avoidance beliefs, especially for those patients with elevated fear-avoidance beliefs. It is not known, however, if these educational approaches also affect pain catastrophizing. The primary purpose of this current study was to investigate the effect of patient education on beliefs associated with LBP. This randomized trial involved 80 subjects (26 males and 54 females) who completed validated measures of disability (Oswestry Disability Questionnaire), pain intensity (numerical rating scale), fear-avoidance beliefs (Fear-Avoidance Beliefs Questionnaire), and pain catastrophizing (Pain Catastrophizing Scale). Subjects were randomly assigned to receive either classification-based physical therapy (n = 27) or behavioral-based physical therapy (n = 53). The behavioral-based physical therapy included graded exercise or graded exposure, as well as an education pamphlet (The Back Book) designed to reduce fear and threat associated with LBP. 68 subjects (85%) were re-assessed after 4-weeks of treatment. Overall, there were significant 4-week improvements in disability, pain intensity, and fear-avoidance beliefs (p < 0.01), but not in pain catastrophizing (p = 0.07). The largest improvement in fear-avoidance beliefs (p < 0.05) was reported for those patients with elevated fear-avoidance beliefs receiving behavioral-based physical therapy. Improvement in pain catastrophizing was not associated with level of fear-avoidance beliefs or group assignment. After controlling for change in pain intensity, only change in fear-avoidance beliefs was predictive of change in disability. In conclusion, current educational modifications appear to effectively reduce fear-avoidance beliefs and these changes predict change in disability from LBP. Definitive changes in pain catastrophizing were not observed in this study, suggesting additional educational strategies may be necessary to effectively reduce pain catastrophizing. This study was supported by a grant from the NIH.