Low back pain is a condition that affects millions of people each year.1–3 Approximately 60% to 80% of the adult population is likely to experience low back pain at some point in their life.1–3 Low back pain can be difficult to treat, not only due to the anatomical structures and mechanisms involved, but also due to the psychological effect resulting from the pain experienced.4–6 The primary structures involved in the diagnosis of low back pain consist of pathology in the intervertebral discs, intervertebral ligaments, vertebral bodies, vertebral facet joints, spinal musculature, and spinal nerves.1,2,7 Damage or pathology to these structures may produce abnormal biomechanics by eliciting pain during movement and disrupting the individual's ability to complete daily tasks normally.8,9 Pain experienced on a consistent basis has a cumulative negative effect on the individual's mental health.10,11 Overall, these experiences can lead to individuals avoiding certain activities,12–14 perceiving greater amounts of pain,3,12,15 decreasing activity altogether,15 and developing depression or anxiety related to their disability.13,14 This pain-related fear is described as fear avoidance belief.3,14
Pain and fear are significant negative psychological and physiologic responses to stimuli that cause disruptions to an individual's normal physical and mental homeostasis.9,10.12 These two experiences together have been described conceptually through a variety of different terminology, including fear avoidance beliefs,3,9,14 kinesiophobia, fear of pain, pain-related fear, and fear of movement.9,12 Negative emotions associated with a painful experience may lead to long-term disability even after the structural or mechanical cause of pain has been treated.6,15,16 It is important that health care providers address an individual's psychological response to the pain experienced by a patient, in conjunction with the pathophysiology, to achieve positive outcomes.10,12,16
There are more than 1 million firefighters in the United States.17 In 2017, there were 58,835 injuries reported by firefighters, with approximately half of those reported injuries being musculoskeletal injuries.18,19 The National Fire Protection Association indicated that 20% of the reported musculoskeletal injuries were related to low back pain.17 Additionally, 50% of all of the line of duty injury retirements were due to low back injury.17 Due to the nature of the tasks associated with the fire service, the potential for higher rates of low back pain may be present compared to the general population. The higher risk of injury may lead to pain-related fear and disability that could influence a firefighter's ability to complete his or her daily and work-related tasks.18,19
Communities large and small rely on members of the fire service for protection in emergency situations. In the event of an emergency, the public assumes that their first responders are healthy and able bodied, yet if firefighters are experiencing pain or pain-related fear, they may have limitations in completing their duties. To the authors' knowledge, no research has been conducted that examines if and how pain-related fear and avoidance beliefs because of low back pain affects firefighters. Therefore, the purpose of this study was to examine the relationship between both fear avoidance beliefs and low back pain in firefighters using patient-reported outcome measures and examine correlations between these patient-reported outcome measures.
We used a cross-sectional design to examine the relationship of fear avoidance beliefs with low back pain in firefighters.
All of the participants in this study were career fire-fighters recruited from a convenience sample at a large fire department that served a mixed metropolitan community in the Midwest.20 Eighty-two participants voluntarily participated in this study. Most (n = 79, 96.3%) were male, with a much smaller sample of female participants (n = 3, 3.7%). The participants were middle aged (41 ± 9 years) and had 16 ± 10 years of fire service experience.
The research team extracted themes from previous literature to create the demographic and low back pain survey for this study (Figure 1).4,10 The demographic survey consisted of four items that identified basic participant information, including age, height, weight, gender, firefighter status (career or volunteer), and years of experience in the fire service. The low back pain survey consisted of three items that asked the participants to self-report their current or past experiences with low back pain. This section of the survey was used to retrospectively assign participants to specific categories to serve as the independent variables. The length of experience with low back pain was categorized into 1 to 6 weeks (acute), 7 to 12 weeks (subacute), and 12+ weeks (chronic) based on the literature's classification system.21–23 Only participants who identified as having a history of low back pain and current low back pain were able to move on to the duration of low back pain category. This was due to the difficulty and inconsistency of asking participants to recall the duration of their low back pain if they were not currently experiencing low back pain.
Low Back Pain Survey.
The dependent variable was the total score on the standard version of the Fear Avoidance Belief Questionnaire (FABQ), Oswestry Disability Index (ODI), and Roland Morris Disability Questionnaire (RMDQ). A second purpose of this study that was determined to be of equal clinical relevance to our initial purpose was to examine the relationship between the FABQ and common patient-reported outcome measures24,25 of low back pain, including the ODI and RMDI.
The FABQ was created to identify pain-related fear and patient perceptions of how pain interferes with physical activity and work abilities. The FABQ measures individuals' perception of their own ability to complete both work and physical activity tasks. High scores indicate elevated levels of fear avoidance beliefs.3,11,24,26 The FABQ is a two-part questionnaire with 16 items that address aspects of their work and physical activity, and more specifically how this pain will limit their ability to complete tasks.3,24,26 Each item of the FABQ is rated on a 6-point Likert scale, with 0 being “do not agree at all” and 6 being “completely agree.”3,26 Two validated variations of the FABQ exist: the work module (7 items) and the physical activity module (4 items).24,26 The FABQ work module is the subscale that was used in this study. The interrater and intrarater reliability of the FABQ is good to excellent, with a Cronbach alpha value of 0.82.26
The ODI is a 10-item questionnaire that addresses a specific activity or aspect of their injury. Each item in the section has a score from 0 to 5, where a score of 0 indicates no disability and 5 indicates severe disability.27–29 The sum of the scores is converted to percentages that indicate severity of disability. Higher scores on the ODI indicate higher percentages of disability.27–29 These percentages are categorized into five groups: 0% to 20% minimal disability, 21% to 40% moderate disability, 41% to 60% severe disability, 61% to 80% crippled, and 81% to 100% completely disabled.27–29 The test–retest reliability values of the ODI range from 0.83 to 0.99 while also demonstrating high responsiveness.29
The RMDQ is a 24-item questionnaire that identifies mild to moderate disability in patients who suffer from acute, subacute, or chronic low back pain.27,29 The sum of the responses to the RMDQ will indicate the amount of disability the individual is experiencing. These scores range from 0, indicating no disability, to 24, indicating maximum disability.29 Test–retest reliability of the RMDQ has been established in various studies ranging from 0.42 poor to 0.91 excellent.27,29 The content and construction validity of the tool has not been appropriately established, but it has been positively correlated with the 36-Item Short Form Scale physical functioning scale, ODI, and Quebec Low Back Scale.27,29
Prior to the start of the project, Indiana State University's Institutional Review Board approved this study. Participants entered a classroom at the fire department training center where they were each provided a research packet. The research packet included informed consent documents outlining the details of the study, a demographic questionnaire and low back pain experiences tool, and patient-reported outcome measures including the FABQ, ODI, and RMDQ. Individual informed consent was gained prior to data collection. The research team provided instructions to the participants on how to complete the instrument packet and the specific tools included within the packet. A member of the research team was designated to administer the packets during all sessions of the data collection process. This member remained with the participants during the completion of the packets in case any questions or concerns were to arise. After completing the instruments, the participants returned the packet to the designated member of the research team. The completion of all of the materials included in the research packet ranged from 10 to 30 minutes depending on the individual experiences of the participants.
Data from the physical packets were transferred to a password-protected custom spreadsheet (Microsoft Excel; Microsoft Corporation, Redmond, WA). The FABQ, ODI, and RMDQ were scored according to tool instruction.25,26,28,29 Data were then transferred into a commercially available statistical analysis software program (SPSS version 25; IBM Corporation, Armonk, NY). Demographic data were analyzed using measures of means, standard deviations, and frequencies. To analyze the relationships between previous, current, and length of low back pain and FABQ scores, we used the effect sizes (η and η2) to determine the strength of the relationship between the nominal variables of previous, current, and length of low back pain and the total FABQ scores.4,21,24 This statistical test was chosen to determine the strength of the relationship between nominal (previous, current, and length of low back pain) and interval (FABQ scores) data collected with a η2 value from 0.01 to 0.06 indicating a weak effect, from 0.07 to 0.14 indicating a moderate effect, and greater than 0.14 indicating a large effect. We used a Pearson correlation coefficient to examine the relationship between the FABQ score and ODI score, as well as between the FABQ score and the RMDQ score.
Demographic and Low Back Pain Characteristics
From the sample of 82 participants, 93.9% of participants reported that they had previously experienced low back pain. For those who identified current low back pain, 77.8% of the participants reported it was chronic in nature. Participants who identified as experiencing (current or previous) low back pain demonstrated higher scores on the tools compared to the participants who had never experienced low back pain. Additionally, participants currently experiencing low back pain reported higher levels of fear avoidance beliefs and disability when compared to those who were not currently experiencing low back pain. When comparing the relationship between all three tools and duration of low back pain, the chronic subgroup displayed the highest levels of fear avoidance beliefs and disability. In comparison to the overall tools, the mean total score reported by all participants indicated minimal to moderate fear avoidance beliefs and disability. The reported scores of the FABQ were consistent with previous literature, but the scores on the ODI and RMDQ were significantly lower than the averages reported in previous studies.4,10,15 The mean patient-reported outcome measure scores as identified by low back pain characteristics are available in Table 1.
Low Back Pain and Fear Avoidance Beliefs
Correlation coefficients (η and η2) were computed across the three self-reported low back pain patient-reported outcome measures. The results of the analysis identified a statistically significant relationship for the three items on the low back pain survey; all indicated positive effects to the FABQ total ranging from small to large. The analysis between participants currently experiencing low back pain and FABQ scores indicated a positive, large effect (η = 0.557, η2 = 0.310). The analysis between low back pain experience and total FABQ score indicated a positive, moderate effect (η = 0.356, η2 = 0.127). The analysis between the duration of low back pain and FABQ scores indicated a positive, small effect (η = 0.235, η2 = 0.05).
Fear Avoidance Beliefs and Disability
Pearson correlation coefficients were used to identify the relationships between patient-reported outcome measures. Table 2 lists the correlations between the FABQ total to ODI total and RMDQ total. The results demonstrated a strong positive correlation between the FABQ and ODI (r = 0.66, P = .001). A strong positive correlation was established between the ODI and RMDQ (r = 0.79, P = .001). A moderately positive correlation was established between the FABQ and RMDQ (r = 0.44, P = .001).
Means, Standard Deviations, and Intercorrelations for the FABQ, ODI, and RMDQ Total Scores
The results of the patient-reported outcome measures appeared consistent with the understanding of fear avoidance beliefs from previous literature.4,21,24,25 The results of this study demonstrated significant correlations between items on the low back pain survey to the FABQ. Additionally, we were able to establish significantly positive correlations between the FABQ, ODI, and RMDQ. In the low back pain survey, the relationships were between low back pain experience (moderate effect) and current low back pain (large effect) to higher scores on the FABQ. Although duration of low back pain was correlated to the FABQ, it was a weak effect indicating little influence on higher scores on the FABQ.
Low Back Pain and Fear Avoidance Beliefs
Extensive research conducted in fear avoidance beliefs identified relationships to fear avoidance beliefs as a result of injury in the general and athletic population.3–6,8–12,15,16,20–22,24,25 However, firefighters fall into a category of individuals that is separate from both the general population and the athletic population due to the unique physical demands and hazardous work environments.19 Without the appropriate supporting evidence, low back pain in firefighters may have had a different impact than other populations studied in previous literature. However, an understanding of the relationship between fear avoidance beliefs and low back pain has now been established within this specific population.
Fear Avoidance Beliefs and Disability
Previous research in fear avoidance beliefs was able to identify relationships between low back pain and self-reported measures of both fear avoidance beliefs and disability in the general population.4,5,11,25 Three studies investigating relationships between disability scores and low back pain demonstrated significant, positive relationships among low back pain, FABQ, ODI, and RMDQ that were similar to the result of our study.4,21,23 The strength of the relationship between the low back pain characteristics (items similar to those on the low back pain survey in our study) and disability scores in previous studies were consistent to our results. Additionally, the strength of the relationships between the FABQ, ODI, and RMDQ were found to be mostly consistent with the findings in this study; however, we did identify variations in the reported strength of relationship between studies. Variations were consistently reported in these studies in the range between moderate and large.4,20,21 When compared to the previous literature, our results suggest that firefighters respond to low back pain and fear avoidance beliefs in a manner similar to that of the general population with the same injury and beliefs.
With an understanding of the relationships between fear avoidance beliefs and low back pain, health care providers have evidence to help guide their clinical decision-making in firefighters seeking treatment for low back pain. Patients who report having a previous history of or are currently experiencing low back pain have a higher likelihood of fear avoidance beliefs. This may encourage clinicians to incorporate interventions into their treatment plan that emphasize the treatment of fear avoidance beliefs before they cause long-term impairment and rehabilitation complications. Current literature has sought to identify effective interventions in the treatment of fear avoidance beliefs.31 Researchers have identified patient education as the most effective intervention when treating patients with fear avoidance beliefs.31 Other interventions such as exercise and graded exposure tasks have also been investigated with some promise of efficacy.31 Although fear avoidance beliefs are most common in patients with low back pain, other injuries are at risk for the development of these pain catastrophizing and fear of movement beliefs. When comparing the results of our study to previous literature,4,10,11,15,25 we also investigated studies that were examining relationships between fear avoidance beliefs and injuries not related to low back pain. One particular study investigated the relationship between fear avoidance beliefs and anterior cruciate ligament injury,30 which identified a significant relationship between six different outcome scores to functional ability measured by scores on the knee outcome score activities of daily living and sport activity subscales.30 The results demonstrated a significant relationship between higher scores on the FABQ to lower scores on the knee outcome score in both subscales.30 Additionally, a significant relationship was identified between knee surgery after anterior cruciate ligament reconstruction and lower scores on the knee outcome scores.30 The results of our study further support the claims of previous literature; when decreased function or disability are present as a result of injury, levels of fear avoidance beliefs are elevated. Together, this suggests that athletic trainers and other health care providers providing care to the fire service must consider not only the pathophysiology of an injury, but also potential negative psychological effects of an injury using a multi-dimensional approach to care. Health care providers can no longer only address the physical dimension of health in the care they provide to patients.
Limitations and Future Research
The purpose of this research was to bridge the gap in research between the knowledge of the general and athletic populations and the fire service regarding low back pain. In doing so, the results of this study provide foundational information for future research. One limitation of the current study was the use of a convenience sample. This limits the current results because they may not be applicable to firefighters from different regions of the United States and serving different-sized communities. A second limitation was the lack of established reliability of the low back pain survey. Although the demographic items do not require validation, the low back pain survey items on duration of symptoms were created from the literature. The research team did not seek an independent panel to review the final tool, which may limit reproducibility in future studies. Future research should consider a national sample of fire-fighters serving different types of communities. Another possibility for future research is to prospectively examine the development of fear avoidance beliefs following an injury leading to low back pain. Additionally, future research should explore a multi-dimensional approach to the treatment of low back pain in the fire service that addresses the multiple dimensions of health as part of the prevention and treatment strategy.
Implications for Clinical Practice
Our study aimed to improve upon existing knowledge related to health care experiences for members of the fire service. By highlighting the relationships between patient-reported outcome measures and self-reported low back pain, health care providers can evaluate how they currently practice and determine whether this information can drive change in their practice. The results of this study inform the development of screening policy, prevention strategies, and intervention programs in the fire service, particularly as it relates to the need for a multidimensional approach to care.
Evidence suggests that fear avoidance beliefs are positively correlated to low back pain in firefighters. Low back pain experience and current low back pain demonstrated the strongest correlation to higher scores on the FABQ. Additionally, the FABQ, ODI, and RMDQ were correlated when used in the fire service population. This is consistent with the findings in studies examining fear avoidance beliefs in the general population.
- Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet. 2012;379:482–491. doi:10.1016/S0140-6736(11)60610-7 [CrossRef]
- Hoy D, Brooks P, Blyth F, Buchbinder R. The epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010;24:769–781. doi:10.1016/j.berh.2010.10.002 [CrossRef]
- Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993;52:157–168. doi:10.1016/0304-3959(93)90127-B [CrossRef]8455963
- Chung EJ, Hur YG, Lee BH. A study of the relationship among fear-avoidance beliefs, pain and disability index in patients with low back pain. J Exerc Rehabil. 2013;9:532–535. doi:10.12965/jer.130079 [CrossRef]
- George SZ, Stryker SE. Fear-avoidance beliefs and clinical outcomes for patients seeking outpatient physical therapy for musculoskeletal pain conditions. J Orthop Sports Phys Ther. 2011;41:249–259. doi:10.2519/jospt.2011.3488 [CrossRef]21335927
- van Middelkoop M, Rubinstein SM, Kuijpers T, et al. A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. Eur Spine J. 2011;20:19–39. doi:10.1007/s00586-010-1518-3 [CrossRef]
- Steele J, Bruce-Low S, Smith D, Jessop D, Osborne N. A randomized controlled trial of limited range of motion lumbar extension exercise in chronic low back pain. Spine. 2013;38:1245–1252. doi:10.1097/BRS.0b013e318291b526 [CrossRef]23514876
- Holm I, Friis A, Storheim K, Brox JI. Measuring self-reported functional status and pain in patients with chronic low back pain by postal questionnaires: a reliability study. Spine. 2003;28:828–833. doi:10.1097/01.BRS.0000058931.31599.E2 [CrossRef]12698128
- Vlaeyen JW, Kole-Snijders AM, Boeren RG, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62:363–372. doi:10.1016/0304-3959(94)00279-N [CrossRef]8657437
- Fritz JM, George SZ, Delitto A. The role of fear-avoidance beliefs in acute low back pain: Relationships with current and future disability and work status. Pain. 2001;94:7–15. doi:10.1016/S0304-3959(01)00333-5 [CrossRef]11576740
- Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. Spine J. 2014;14:816–836. doi:10.1016/j.spinee.2013.09.036 [CrossRef]24412032
- Lundberg M, Grimby-Ekman A, Verbunt J, Simmonds MJ. Pain-related fear: a critical review of the related measures. Pain Res Treat. 2011;2011:494196.22191022
- Chung YK, Park CY. The effects of injury and accidents on self-rated depression in male municipal firefighters. Safe Health Work. 2011;2:158–168. doi:10.5491/SHAW.2011.2.2.158 [CrossRef]
- Lethem J, Slade PD, Troup JD, Bentley G. Outline of a Fear-Avoidance Model of exaggerated pain perception. Behav Res Ther. 1983;21:401–408. doi:10.1016/0005-7967(83)90009-8 [CrossRef]
- Crombez G, Vlaeyen JWS, Heuts PHTG, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain. 1999;80:329–339. doi:10.1016/S0304-3959(98)00229-2 [CrossRef]10204746
- Grotle M, Vollestad NK, Brox JI. Clinical course and impact of fear-avoidance beliefs in low back pain: prospective cohort study of acute and chronic low back pain: II. Spine. 2006;31:1038–1046. doi:10.1097/01.brs.0000214878.01709.0e [CrossRef]16641782
- Evarts B, Molis JL. United States Firefighter Injuries 2017. National Fire Protection Association; 2018. Retrieved from: https://www.nfpa.org/News-and-Research/Publications/NFPA-Journal/2018/November-December-2018/Features/US-Firefighter-Injuries-2017
- Conrad KM, Balch GI, Reichelt PA, Muran S, Oh K. Musculoskeletal injuries in the fire service: views from a focus group study. AAOHN J. 1994;42:572–581. doi:10.1177/216507999404201201 [CrossRef]7893285
- Reichard AA, Jackson LL. Occupational injuries among emergency responders. Am J Ind Med. 2010;53:1–11.
- U.S. Census Bureau QuickFacts: Terre Haute, Indiana. Census Bureau QuickFacts. 2017. https://www.census.gov/quickfacts/fact/table/terrehautecityindiana/PST045217. Accessed March 14, 2019.
- Wand BM, Chiffelle LA, O'Connell NE, McAuley JH, Desouza LH. Self-reported assessment of disability and performance-based assessment of disability are influenced by different patient characteristics in acute low back pain. Eur Spine J. 2010;19:633–640. doi:10.1007/s00586-009-1180-9 [CrossRef]
- Maughan EF, Lewis JS. Outcome measures in chronic low back pain. Eur Spine J. 2010;19:1484–1494. doi:10.1007/s00586-010-1353-6 [CrossRef]20397032
- Deyo RA, Battie M, Beurskens AJHM, et al. Outcome measures for low back pain research: a proposal for standardized use. Spine. 1998;23:2003–2013. doi:10.1097/00007632-199809150-00018 [CrossRef]
- Fritz JM, George SZ. Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fear-avoidance beliefs. Phys Ther. 2002;82:973–983.12350212
- Cai C, Pua YH, Lim KC. Correlates of self-reported disability in patients with low back pain: the role of fear-avoidance beliefs. Ann Acad Med Singapore. 2007;36:1013–1020.
- Pfingsten M, Kroner-Herwig B, Leibing E, Kronshage U, Hildebrandt J. Validation of the German version of the Fear-Avoidance Beliefs Questionnaire (FABQ). Eur J Pain. 2000;4:259–266. doi:10.1053/eujp.2000.0178 [CrossRef]10985869
- Monticone M, Baiardi P, Vanti C, et al. Responsiveness of the Oswestry Disability Index and the Roland Morris Disability Questionnaire in Italian subjects with sub-acute and chronic low back pain. Eur Spine J. 2012;21:122–129. doi:10.1007/s00586-011-1959-3 [CrossRef]
- Vianin M. Psychometric properties and clinical usefulness of the Oswestry Disability Index. Journal of Chiropractic Medicine. 2008;7:161–163. doi:10.1016/j.jcm.2008.07.001 [CrossRef]
- Roland M, Fairbank J. The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire. Spine. 2000;25:3115–3124. doi:10.1097/00007632-200012150-00006 [CrossRef]11124727
- Ross MD. The relationship between functional levels and fear-avoidance beliefs following anterior cruciate ligament reconstruction. J Orthop Traumatol. 2010;11:237–243. doi:10.1007/s10195-010-0118-7 [CrossRef]21116674
- Guck TP, Burke RV, Rainville C, Hill-Taylor D, Wallace DP. A brief primary care intervention to reduce fear of movement in chronic low back pain patients. Transl Behav Med. 2015;5:113–121. doi:10.1007/s13142-014-0292-x [CrossRef]25729460
|LBP experience (n = 82)|
| Yes||77||93.9||22.25 ± 14.5||3.38 ± 3.85||1.61 ± 3.46|
| No||5||6.1||0 ± 0||0 ± 0||0 ± 0|
|Current LBP (n = 77)|
| Yes||36||46.8||30.83 ± 11.55||5.83 ± 4.16||3.00 ± 4.59|
| No||41||53.2||14.71 ± 12.64||1.22 ± 1.66||0.39 ± 1.05|
|Duration of LBP (n = 36)|
| Acute||6||16.7||32.17 ± 9.45||5.50 ± 3.21||0.50 ± 1.23|
| Subacute||2||5.6||20.00 ± 2.83||3.50 ± 2.12||4.00 ± 4.24|
| Chronic||28||77.7||31.21 ± 12.11||6.07 ± 4.46||3.46 ± 4.96|
Means, Standard Deviations, and Intercorrelations for the FABQ, ODI, and RMDQ Total Scores
| Pearson correlation||–||.660a||.448a|
| P (2-tailed)||–||.001||.001|
| Standard deviation||–||15.05||3.375|
| Standard deviation||3.813||–||3.375|