The patient was a 57-year-old woman who was referred to a physical therapist in an outpatient setting 8 weeks following an open reduction internal fixation procedure for a left patellar fracture following a fall where the patient landed directly on her left knee in a flexed position. The patient’s treatment plan was established and consisted of range-of-motion and resistive exercises, and she was scheduled to see the physical therapist again in 5 days. At the time of her follow-up visit, however, the patient reported falling 3 days earlier, which caused increased left knee pain and difficulty with weight bearing. The patient was referred to her orthopaedic surgeon, where radiographs revealed orthopaedic fixation of a healing patella fracture. However, the patella was high riding, consistent with a patellar tendon rupture.

J Orthop Sports Phys Ther 2012;42(11):969. doi:10.2519/jospt.2012.0419

KEY WORDS: knee, patella, radiography

STUDY DESIGN: Cross-sectional. OBJECTIVES: To evaluate the accuracy with which physical therapists identify fear-avoidance beliefs in patients with low back pain by comparing therapist ratings of perceived patient fear-avoidance to the Fear-Avoidance Beliefs Questionnaire (FABQ), Tampa Scale of Kinesiophobia 11-item (TSK-11), and Pain Catastrophizing Scale (PCS). To compare the concurrent validity of therapist ratings of perceived patient fear-avoidance and a 2-item questionnaire on fear of physical activity and harm, with clinical measures of fear-avoidance (FABQ, TSK-11, PCS), pain intensity as assessed with a numeric pain rating scale (NPRS), and disability as assessed with the Oswestry Disability Questionnaire (ODQ). BACKGROUND: The need to consider psychosocial factors for identifying patients at risk for disability and chronic low back pain has been well documented. Yet the ability of physical therapists to identify fear-avoidance beliefs using direct observation has not been studied. METHODS: Eight physical therapists and 80 patients with low back pain from 3 physical therapy clinics participated in the study. Patients completed the FABQ, TSK-11, PCS, ODQ, NPRS, and a dichotomous 2-item fear-avoidance screening questionnaire. Following the initial evaluation, physical therapists rated perceived patient fear-avoidance on a 0-to-10 scale and recorded 2 influences on their ratings. Spearman correlation and independent t tests determined the level of association of therapist 0-to-10 ratings and 2-item screening with fear-avoidance and clinical measures. RESULTS: Therapist ratings of perceived patient fear-avoidance had fair to moderate interrater reliability (ICC_2,1 = 0.663). Therapist ratings did not strongly correlate with FABQ or TSK-11 scores. Instead, they unexpectedly had stronger associations with ODQ and PCS scores. Both 2-item screening questions were associated with FABQ-physical activity scores, while the fear of physical activity question was also associated with FABQ-work, TSK-11, PCS, and ODQ scores. CONCLUSION: Therapists’ ratings of perceived patient fear-avoidance were not associated with self-reported fear-avoidance scores, showing a potential disconnect between therapist judgments and commonly used fear-avoidance measures. Instead, therapist ratings had small but statistically significant correlations with pain catastrophizing and disability, findings that may support therapists’ inability to discriminate fear-avoidance from these other factors. The 2-item screening questions based on fear of physical activity and harm showed potential to identify elevated FABQ physical activity scores. LEVEL OF EVIDENCE: Differential diagnosis, level 2b.

J Orthop Sports Phys Ther 2010;40(12):774-783, Epub 22 October 2010. doi:10.2519/jospt.2010.3381

KEY WORDS: FABQ, low back pain, screening