Baez S, Hoch MC, Hoch JM 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. Arch Phys Med Rehabil. 2018 Nov;99(11):2287-2298. doi: 10.1016/j.apmr.2017.11.003. Epub 2017 Dec 14. (Systematic review)

OBJECTIVES: 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.

CONCLUSIONS: 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.

Discipline Area Score
Rehab Clinician (OT/PT) 6 / 7
Psychologist 6 / 7
Physician 5 / 7
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Comments from MORE raters

Physician rater

While this is a negative study, it has some importance showing that the intervention did not work in the majority of studies.

Rehab Clinician (OT/PT) rater

The patient oriented evidence evaluation is especially interesting and valuable in this review.

Rehab Clinician (OT/PT) rater

As both chronic and acute low back pain are now understood to have both physical and emotional components, it is quite important that practitioners know how to evaluate and address the emotional impact of pain. This review is a good summary of the existing research on effective approaches to dealing with fear-avoidance and kinesiophobia. The review, however, included only five studies and rejected 25. One reason might be that the authors used "specified pathologies, i.e. disk degeneration" as an exclusion criteria. This is puzzling, as most individuals over the age of 30 will likely have some "disk degeneration" and the presence of such does not correlate with degree of symptoms. Perhaps the review would have been more all-encompassing with less strict criteria. Nevertheless, it's worth a read for clinicians treating low back pain.

Rehab Clinician (OT/PT) rater

Occupational therapists would benefit from considering the role of CBT in addressing avoidant behavior for people with low back pain or other painful orthopedic conditions.
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