Fear of movement/(re)injury in chronic low back pain: education or exposure in vivo as mediator to fear reduction?

Clinical research of graded exposure in vivo with behavioral experiments in patients with chronic low back pain who reported fear of movement/(re)injury shows abrupt changes in self-reported pain-related fears and cognitions. The abrupt changes are more characteristics of insight learning rather than the usual gradual progression of trial and error learning. The educational session at the start of the exposure might have contributed to this insight. The current study examines the contribution of education and graded exposure versus graded activity in the reduction of pain-related fear and associated disability and physical activity. Six consecutive patients with chronic low back pain who reported substantial fear of movement/(re)injury were included in the study. After a no-treatment baseline measurement period, all the patients received a single educational session, followed again by a no-treatment period. Patients were then randomly assigned to either a graded exposure with behavioral experiments or an operant graded activity program. A diary was used to assess daily changes in pain intensity, pain-related fear, pain catastrophizing, and activity goal achievement. Standardized questionnaires of pain-related fear, pain vigilance, pain intensity, and pain disability were administered before and after each intervention and at the 6-month follow-up. An activity monitor was carried at baseline, during the interventions, and 1 week at 6-month follow-up. Randomization tests of the daily measures showed that improvements in pain-related fear and catastrophizing occurred after the education was introduced. The results also showed a further improvement when exposure in vivo followed the no-treatment period after the education and not during the operant graded activity program. Performance of relevant daily activities, however, were not affected by the educational session and improved significantly only in the exposure in vivo condition. All improvements remained at half-year follow-up only in patients receiving the exposure in vivo. These patients also reported a significant decrease in pain intensity at follow-up.     

Reduction of Pain-Related Fear and Disability in Post-Traumatic Neck Pain: A Replicated Single-Case Experimental Study of Exposure In Vivo

For patients with acute post-traumatic neck pain (PTNP), pain-related fear has been identified as a potential predictor of chronic disability. If such is the case, fear reduction should enhance the prevention of further pain disability and distress after traumatic neck pain disability. However, exposure-based treatments have not been tested in patients with PTNP. Using a replicated single-case crossover phase design with multiple measurements, this study examined whether the validity of a graded exposure in vivo, as compared with usual graded activity, extends to PTNP. Eight patients who reported substantial pain-related fear were included in the study. Daily changes in pain intensity, pain-related fear, pain catastrophizing, and activity goal achievement were assessed. Before and after each intervention, and at 6-month follow-up, standardized questionnaires of pain-related fear and pain disability were administered, and, to quantify daily physical activity level, patients carried an ambulatory activity monitor. The results showed decreasing levels of self-reported pain-related fear, pain intensity, disability, and improvements in physical activity level only when graded exposure in vivo was introduced, and not in the graded activity condition. The results are discussed in the context of the search for customized treatments for PTNP.PerspectiveThis is the first study showing that the effects of graded exposure in vivo generalize to patients with chronic PTNP reporting elevated levels of pain-related fear. This could help clinicians to customize treatments for PTNP.     

Reduction of pain-related fear and increased function and participation in work-related upper extremity pain (WRUEP): Effects of exposure in vivo

There is increasing evidence that pain-related fear influences the development and maintenance of pain disability, presumably mediated through the fear-related avoidance of valued activities. Individually tailored graded exposure in vivo (GEXP) has been demonstrated to reduce pain-related fear and increase functional abilities in patients with chronic low back pain, neck pain, and complex regional pain syndrome. The current study aimed to test whether these effects generalize towards patients with work-related upper extremity pain. A sequential replicated and randomized single-case experimental phase design with multiple measurements was used. Within each participant, GEXP was compared to a no-treatment baseline period and a no-treatment 6-month follow-up period. Eight patients who reported a high level of pain-related fear were included in the study. Daily changes in pain catastrophizing, pain-related fear, and pain intensity were assessed using a diary, and subjected to randomization tests. Before the start of the baseline period, just after GEXP, and at 6-month follow-up, clinically relevant changes of pain catastrophizing, pain-related fear, perceived harmfulness of physical activity, pain disability, and participation/autonomy were verified. When GEXP was introduced, levels of pain catastrophizing and pain-related fear decreased significantly. Clinically relevant improvements were observed for pain disability, perceived participation, and autonomy. These favourable changes were maintained until 6-month follow-up. The findings of the current study underscore the external validity of a cognitive-behavioural GEXP treatment for patients with chronic pain reporting increased pain-related fear.     

Evaluating the efficacy of graded in vivo exposure for the treatment of fear in patients with chronic back pain: a randomized controlled clinical trial

Psychological treatments for chronic pain, particularly those based upon cognitive behavioural principles, have generally been shown to be efficacious. Recently, a treatment has been developed based upon the fear-avoidance model of chronic musculoskeletal pain, which suggests chronic pain can be relieved by exposing the individual to movements and tasks that have been avoided due to fear of (re)injury. This graded in vivo exposure treatment has been found to be beneficial in case studies. The present investigation utilized a randomized controlled trial method to assess the effectiveness of graded in vivo exposure relative to other conditions. Forty-four chronic low back pain patients were randomly assigned to graded in vivo exposure, graded activity, or a wait-list condition. While only trend differences were observed for pain-related disability, patients in the graded in vivo exposure condition demonstrated (a) significantly greater improvements on measures of fear of pain/movement, fear avoidance beliefs, pain-related anxiety, and pain self-efficacy when compared to those in the graded activity condition, and (b) significantly greater improvements on measures of fear-avoidance beliefs, fear of pain/movement, pain-related anxiety, pain catastrophising, pain experience, and anxiety and depression when compared to those in the wait-list control condition. Additionally, patients in the graded in vivo exposure condition maintained improvements in these areas at one month follow-up. Implications of these findings for the treatment of individuals with chronic low back and other pain conditions are discussed.     

Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability

There is growing evidence for the idea that in back pain patients, pain-related fear (fear of pain/physical activity/(re)injury) may be more disabling than pain itself. A number of questionnaires have been developed to quantify pain-related fears, including the Fear-Avoidance Beliefs Questionnaire (FABQ), the Tampa Scale for Kinesiophobia (TSK), and the Pain Anxiety Symptoms Scale (PASS). A total of 104 patients, presenting to a rehabilitation center or a comprehensive pain clinic with chronic low back pain were studied in three independent studies aimed at (1) replicating that pain-related fear is more disabling than pain itself (2) investigating the association between pain-related fear and poor behavioral performance and (3) investigating whether pain-related fear measures are better predictors of disability and behavioral performance than measures of general negative affect or general negative pain beliefs (e.g. pain catastrophizing). All three studies showed similar results. Highest correlations were found among the pain-related fear measures and measures of self-reported disability and behavioral performance. Even when controlling for sociodemographics, multiple regression analyses revealed that the subscales of the FABQ and the TSK were superior in predicting self-reported disability and poor behavioral performance. The PASS appeared more strongly associated with pain catastrophizing and negative affect, and was less predictive of pain disability and behavioral performance. Implications for chronic back pain assessment, prevention and treatment are discussed.     

Exposure in vivo versus operant graded activity in chronic low back pain patients: results of a randomized controlled trial

Since pain-related fear may contribute to the development and maintenance of chronic low back pain (CLBP), an exposure in vivo treatment (EXP) was developed for CLBP patients. We examined the effectiveness as well as specific mediating mechanisms of EXP versus operant graded activity (GA) directly and 6 months post-treatment in a multi-centre randomized controlled trial. In total, 85 patients suffering from disabling non-specific CLBP reporting at least moderate pain-related fear were randomly allocated to EXP or GA. It was demonstrated that EXP, despite excelling in diminishing pain catastrophizing and perceived harmfulness of activities, was equally effective as GA in improving functional disability and main complaints, although the group difference almost reached statistical significance favouring EXP. Both treatment conditions did not differ in pain intensity and daily activity levels either. Nor was EXP superior to GA in the subgroup of highly fearful patients. Irrespective of treatment, approximately half the patients reported clinically relevant improvements in main complaints and functional disability, although for the latter outcome the group difference was almost significant favouring EXP. Furthermore, the effect of EXP relative to GA on functional disability and main complaints was mediated by decreases in catastrophizing and perceived harmfulness of activities. In sum, this study demonstrates that up to 6 months after treatment EXP is an effective treatment, but not more effective than GA, in moderately to highly fearful CLBP patients, although its superiority in altering pain catastrophizing and perceived harmfulness of activities is clearly established. Possible explanations for these findings are discussed.     

Decline in physical activity, disability and pain-related fear in sub-acute low back pain.

AIM OF INVESTIGATION: To evaluate whether a perceived decline in the level of physical activity after the onset of pain (PAD) is more appropriate in the explanation of disability as compared to the actual level of physical activity (PAL) in patients with sub-acute back pain. METHODS: Patients with 4-7 weeks of non-specific low back pain (LBP) participated in this study. Their habitual physical activity level before the back pain started (H-PAL), their actual level of physical activity (PAL) and their perceived decline in the level of physical activity after the onset of pain (PAD) were assessed. The association between these physical activity related variables and perceived disability (QBPDS), fear of movement/(re)injury (TSK), pain catastrophizing (PCS) and pain intensity (VAS) was examined. The role of PAD as a mediator in the association between fear of movement/(re)injury and disability was examined by three linear regression analyses. RESULTS: 123 patients (66 male and 57 female) with a mean age of 44.1 years (SD=10.3) participated in this study. PAD was significantly correlated with disability, fear of movement/(re)injury, pain catastrophizing and pain intensity. PAD and PAL appeared more important in the explanation of disability in the subgroup of patients who were physically active before their back pain started. Generally, PAD indeed mediated the association between fear of movement/(re)injury and disability. CONCLUSIONS: The perceived decline in physical activity, rather than the current physical activity itself is important in the evaluation of the impact of activity related changes on disability in low back pain.     

Self-efficacy mediates the relation between pain-related fear and outcome in chronic low back pain patients.

This study aimed to determine whether self-efficacy beliefs mediated the relation between pain-related fear and pain, and between pain-related fear and disability in CLBP patients who exhibited high pain-related fear. In a cross-sectional design, 102 chronic low back pain (CLBP) patients completed measures for pain, disability, self-efficacy and pain-related fear (fear of movement and catastrophizing). Multistep regression analyses were performed to determine whether self-efficacy mediated the relation between pain-related fear and outcome (pain and/or disability). Self-efficacy was found to mediate the relation between pain-related fear and pain intensity, and between pain-related fear and disability. Therefore, this study suggests that when self-efficacy is high, elevated pain-related fear might not lead to greater pain and disability. However, in instances where self-efficacy is low, elevated pain-related fear is likely to lead to greater pain and disability. In view of these findings, we conclude that it is imperative to assess both pain-related fear and self-efficacy when treating CLBP patients with high pain-related fear.     

Acute low back pain: pain-related fear and pain catastrophizing influence physical performance and perceived disability

Pain-related fear and pain catastrophizing are associated with disability and actual performance in chronic pain patients. In acute low back pain (LBP), little is known about the prediction of actual performance or perceived disability by pain-related fear and pain catastrophizing. This experimental, cross-sectional study aimed at examining whether pain-related fear and pain catastrophizing were associated with actual performance and perceived disability. Ninety six individuals with an episode of acute LBP performed a dynamic lifting task to measure actual performance. Total lifting time was used as outcome measure. The results show that pain-related fear, as measured with the Tampa Scale for Kinesiophobia, was the strongest predictor of this physical task. Using the Roland Disability Questionnaire as a measure of perceived disability, both pain-related fear and pain catastrophizing, as measured with the Pain Catastrophizing Scale, were significantly predictive of perceived disability and more strongly than pain intensity was. The results of the current study suggest that pain-related fear is an important factor influencing daily activities in individuals suffering an episode of acute LBP. The study results have important clinical implications, especially in the development of preventive strategies for chronic LBP.     

The joint contribution of physical pathology, pain-related fear and catastrophizing to chronic back pain disability

The present study examined the contribution of physical pathology, pain-related fear and catastrophizing cognitions to pain intensity and disability in 100 patients with non-specific low back pain. Self-report instruments were completed as part of the intake procedure of patients, while physical pathology was quantified from medical charts using the MEDICS procedure. Results of the multiple regression analyses, adjusted for relevant demographic variables, pain intensity and pain duration, indicated that physical pathology was associated with pain intensity, but not with self-reported physical disability. Disability showed the strongest association with pain intensity. However, pain-related fear and catastrophizing contributed 4-10% additional explained variance to the regression models for pain intensity and disability. Thus, this study confirms the relationship between biological and psychological variables in determining the severity of low back pain complaints, and underscores the necessity for a multidisciplinary approach to diagnostics and intervention.     

The role of neuroticism, pain catastrophizing and pain-related fear in vigilance to pain: a structural equations approach

The present study aimed at clarifying the precise role of pain catastrophizing, pain-related fear and personality dimensions in vigilance to pain and pain severity by means of structural equation modelling. A questionnaire survey was conducted in 122 patients with chronic or recurrent low back pain. Results revealed that pain catastrophizing and pain-related fear mediated the relationship between neuroticism and vigilance to pain. Furthermore, vigilance to pain was found to be associated with heightened pain severity. Finally, we found that neuroticism moderated the relationship between pain severity and catastrophic thinking about pain. The results strongly support the idea that vigilance to pain is dependent upon catastrophic thinking and pain-related fear. Neuroticism is best conceived of as a vulnerability factor; it lowers the threshold at which pain is perceived as threatening, and at which catastrophic thoughts about pain emerge.     

Differential predictors of the long-term levels of pain intensity, work disability, healthcare use, and medication use in a sample of workers' compensation claimants

The fear avoidance model of pain (FAM) conceptualizes pain catastrophizing as the cognitive antecedent of pain-related fear, and pain-related fear as the emotional antecedent of depression and disability. The FAM is essentially one of mediation whereby pain-related fear becomes the process by which depression or disability ensue. However, emerging literature suggests that pain catastrophizing, pain-related fear, and depression might be at least partially distinct in their prediction of different pain-related outcomes. The primary purpose of the present study was to evaluate whether psychological factors in the FAM (pain catastrophizing, pain-related fear, and depression) differentially predict long-term pain-related outcomes. Toward this objective, we conducted a prospective study using a cohort of 202 individuals with subacute work-related musculoskeletal injuries. Participants completed a 7-week physical therapy program with a functional rehabilitation orientation. Posttreatment measures of fear of movement, pain catastrophizing, depression, and pain self-efficacy were used to predict the persistence of pain symptoms, healthcare use, medication use, and return-to-work at one-year follow-up. Results from hierarchical linear and logistic regression analyses revealed that pain catastrophizing and fear of movement act as differential predictors of long-term pain-related outcomes. Specifically, we found unique relationships between pain catastrophizing and long-term pain intensity, and fear of movement and long-term work disability. After controlling for pain intensity and FAM variables, pain self-efficacy was shown to be a unique predictor of medication use. Implications for the FAM and the clinical management of musculoskeletal pain conditions are discussed.     

Reduction of pain-related fear in complex regional pain syndrome type I: the application of graded exposure in vivo

Fear of (re)injury/movement has been identified as a potential predictor of chronic disability in complex regional pain syndrome type I (CRPS-I). In order to reduce pain-related fears and pain disability, graded exposure in vivo (GEXP) is likely to be an appropriate treatment. Indeed, there is evidence that in chronic pain patients reporting substantial fear of (re)injury/movement, GEXP is successful in reducing pain disability. However, the efficacy of exposure-based protocols in the treatment of CRPS-I patients for reducing pain disability has not been tested. The main research question of this study was whether the reduction of pain-related fear through GEXP also resulted in a decrease of disability in a subgroup of patients with CRPS-I who report substantial pain-related fear. A single-case experimental ABCD-design was used with random determination of the start of the intervention. Eight patients with CRPS-I were included in the study. To assess daily changes in pain intensity, pain-related fear, pain catastrophizing, and activity goal achievement, a diary was used. Standardized questionnaires of pain-related fear, pain disability, and self-reported signs and symptoms of CRPS-I were administered before and after each intervention, and at 6-month follow-up. The current study supports a GEXP approach to chronic CRPS-I. The GEXP was successful in decreasing levels of self-reported pain-related fear, pain intensity, disability, and physiological signs and symptoms. These results support the hypothesis that the meaning people attach to a noxious stimulus influences its experienced painfulness, and that GEXP activates cortical networks and reconciles motor output and sensory feedback.     

Does systematic graded exposure in vivo enhance outcomes in multidisciplinary chronic pain management groups?

OBJECTIVES: Graded exposure in vivo (GEXP) treatment has been successfully used to reduce levels of pain-related fear and disability in some chronic pain patients, but its effectiveness has not been evaluated in general clinical settings using group-design studies. The purpose of this study was to determine if the systematic incorporation of GEXP into a multidisciplinary chronic pain management group (PMG) treatment program would result in better treatment outcomes than usual PMG treatment. METHODS: One hundred forty-three chronic pain patients who were assessed as suitable for an outpatient multidisciplinary chronic PMG program were randomly allocated to 3 experimental conditions; usual PMG, PMG incorporating systematic graded exposure, and wait-list control. RESULTS: The clinical outcomes of the 2 treatment conditions were not significantly different, suggesting that the systematic incorporation of GEXP into a multidisciplinary PMG program did not result in better treatment outcomes than usual PMG treatment. Both group treatment programs were associated with significant treatment effects when compared with the wait-list control on measures of pain intensity, fear of movement/(re)injury, pain self-efficacy, activity level, and depression. No treatment effects were found on self-report measures of pain disability or anxiety. DISCUSSION: The addition of systematic graded exposure into a multidisciplinary chronic pain management program did not result in better clinical outcomes than the usual group treatment program. The validity of GEXP to the broader population of chronic pain patients warrants further investigation.     

Pain-related fear in acute low back pain: the first two weeks of a new episode.

The overall aim of this study was to explore the natural course of pain-related fear during the early stage of a new low back pain episode, using a prospective case series design. Specific research questions addressed the existence of typical patterns in individual time series of pain-related fear and sequential relationships between the occurrence of pain-related fear, pain and pain catastrophizing. Forty-four general practice patients who consulted their physician with a new episode of non-specific low back pain were recruited. They completed diaries on pain-related fear, pain and pain catastrophizing for 14 days following the consultation. Follow-up questionnaires on disability were completed at 3 months and 12 months. Time series analyses produced subgroups of patients with descending, stable and rising levels of pain-related fear over the 2-week period. These groups differed on baseline characteristics and outcome at follow-up. A time-shift between the occurrence of pain-events and pain-related fear or pain catastrophizing could not be demonstrated.In summary, these results fit in with previous findings in chronic patients. A relevant subgroup of patients who might benefit from early intervention could be identified. These findings support the need for further research into fear mechanisms in acute low back pain.     

Get Your Head in the Game: A Replicated Single-Case Experimental Design Evaluating the Effect of a Novel Virtual Reality Intervention in People With Chronic Low Back Pain

Chronic low back pain (CLBP) is a leading cause of disability worldwide. Contemporary treatment of CLBP is suboptimal, with small-moderate effect sizes and high relapse rates. Virtual reality (VR) is an increasingly accessible technology that can improve adherence to exercise programs through gamification. Using VR to facilitate exercise adherence and enjoyment may improve the clinical outcomes. This study aimed to evaluate the effects of a gamified VR graded activity intervention in people with CLBP, using commercially available and bespoke VR programs. A sequentially replicated, multiple-baseline, randomized AB single-case experimental design was undertaken in 10 people with CLBP. Outcomes were assessed daily and included pain intensity (primary) and pain catastrophizing, pain-related fear, and anxiety/worry (secondary). The effect of the intervention on the primary outcome was evaluated using a multilevel-model, nonparametric randomization test. The VR graded activity intervention resulted in a significant reduction in pain intensity (effect estimate = −1.0, standard error = .27, P < .0011) with 4 participants achieving ≥30% pain reduction (minimum important change). There was a significant effect of the intervention on pain catastrophizing but not pain-related fear or anxiety/worry measures. These findings provide preliminary support for a VR graded activity program to reduce pain in people with CLBP.PerspectiveThis novel, VR graded activity intervention reduced pain intensity and catastrophizing in people with CLBP. The intervention also had high adherence and enjoyment. Given that this intervention involved 2 freely available VR programs, it can be easily translated into clinical practice.     

Pain-related fear in low back pain: a prospective study in the general population.

A cognitive behavioural account of chronic low back pain (CLBP) proposes that the relationship between pain catastrophizing and functional disability is mediated by fear of movement/(re)injury. Several clinical studies already demonstrated the contribution of pain catastrophizing and fear of movement/(re)injury in the development and maintenance of CLBP. This study included people with low back pain (LBP) in the general population, and aimed to investigate whether fear of movement/(re)injury mediated the relationship between pain catastrophizing and functional disability, by examining several prerequisites for mediation. Data from the Dutch population-based Musculoskeletal Complaints and Consequences Cohort (DMC(3)) study were used, including 152 people suffering from LBP who completed both a follow-up questionnaire and a baseline questionnaire 6 months previously. This study was unable to demonstrate that the relationship between pain catastrophizing and functional disability was mediated by fear of movement/(re)injury, since the prerequisite that pain catastrophizing and functional disability were related, was not fulfilled. However, pain catastrophizing was significantly related to fear of movement/(re)injury 6 months later, above and beyond other contributing variables such as fear of movement/(re)injury already present at baseline. On its turn, fear of movement/(re)injury was related to functional disability, in addition to pain intensity. Although this study leaves some indistinctness concerning the actual relationships between pain catastrophizing, fear of movement/(re)injury, and functional disability, it does provide some evidence for the contributing role of these factors in LBP in the general population.     

Measuring perceived harmfulness of physical activities in patients with chronic low back pain: the Photograph Series of Daily Activities--short electronic version.

Cognitive-behavioral models of chronic low back pain (CLBP) predict that dysfunctional assumptions about the harmfulness of activities may maintain pain-related fear and disability levels. The Photograph Series of Daily Activities (PHODA) is an instrument to determine the perceived harmfulness of daily activities in patients with CLBP. This study examined the psychometric properties of a short electronic version of the PHODA (PHODA-SeV). The results show that the PHODA-SeV measures a single factor and has a high internal consistency. The test-retest reliability and stability of the PHODA-SeV over a 2-week time interval are good, with discrepancies between 2 measurements over 20 points suggesting true change. The construct validity is supported by the finding that both self-reported pain severity and fear of movement/(re)injury were uniquely related to the PHODA-SeV. Validity is further corroborated by the finding that patients who have received exposure in vivo, that aimed to systematically reduce the perceived harmfulness of activities, had significantly lower PHODA-SeV scores after treatment than patients receiving graded activity that did not address these assumptions. The findings support the PHODA-SeV as a valid and reliable measure of the perceived harmfulness of activities in patients with CLBP. Preliminary normative data of the PHODA-SeV are presented. PERSPECTIVE: This article describes a pictorial measurement tool (PHODA-SeV) for the assessment of the perceived harmfulness of activities in patients with chronic low back pain. The PHODA-SeV has good psychometric properties and can be used to elaborate on the contribution of beliefs about harmful consequences of activities to pain and disability.     

Fear of movement/(re)injury, disability and participation in acute low back pain

Fear of movement/(re)injury and its associated avoidance behavior have shown to be strongly associated with functional disability in chronic low back pain. In acute low back pain disability, the role of pain-related fear has received little research attention so far. Measures of pain-related fear such as the Tampa Scale for Kinesiophobia (TSK) are increasingly being used in primary care. The aim of the present study was: (1). to further investigate the factor structure of the TSK in a population of acute low back pain (LBP) patients in primary care by means of a confirmatory factor analysis (CFA); (2). to examine the relationship between fear of movement/(re)injury and disability, as well as participation in daily and social life activities in 615 acute LBP patients seen by general practitioners and physical therapists in primary care settings; and (3). to examine whether disability mediates the association between pain-related fear and participation. CFA, and a subsequent explorative factor analysis on the TSK revealed a two-factor model. The factors consisted of items associated with 'harm', and items representing the 'avoidance of activity'. Both constructs were significantly associated with disability and participation. Additionally, and in contrast to what is often observed in chronic pain, disability, and to a lesser degree participation, were also associated with pain intensity. Finally, the association between pain-related fear, pain intensity and participation was indeed mediated by disability. The results suggest that early on in the development of LBP disability, the successful reduction of pain-related fear and disability might foster increased participation in daily and social life activities.     

Low levels of physical activity in back pain patients are associated with high levels of fear‐avoidance beliefs and pain catastrophizing

Background and Purpose. Fear‐avoidance beliefs are important determinants for disability in patients with non‐specific low‐back pain (LBP). The association with self‐reported level of physical activity is less known. The aim of the present study was to describe the level of physical activity in patients with chronic non‐specific LBP and its relation to fear‐avoidance beliefs and pain catastrophizing. Method. A cross‐sectional study on 64 patients with chronic non‐specific LBP in primary healthcare. The variables measured and the questionnaires used were: level of physical activity (six‐graded scale); activity limitations (Roland Morris Disability Questionnare (RDQ)); fear‐avoidance beliefs (Tampa Scale of Kinesiophobia (TSK) 13‐item and sub‐scales ‘activity avoidance’ and ‘somatic focus’); and pain catastrophizing (Pain Catastrophizing Scale (PCS)). The level of physical activity was dichotomised into low and high physical activity. Individual median scores on the TSK and PCS scales were used to group the patients into different levels of fear‐avoidance beliefs and pain catastrophizing. Univariate logistic regressions were used to calculate odds ratios for having low physical activity. Results. Patients with low physical activity had significantly higher scores in fear‐avoidance beliefs and pain catastrophizing (p < 0.05). Odds ratios for low level of physical activity were between 4 and 8 (p < 0.05) for patients with high fear‐avoidance beliefs or medium/high pain catastrophizing. Conclusions. This study indicates that it seems important for physiotherapists in primary care to measure levels of fear‐avoidance beliefs or pain catastrophizing. In particular, the two subscales of the TSK could be of real value for clinicians when making treatment decisions concerning physical exercise therapy for patients with chronic LBP. Copyright © 2007 John Wiley & Sons, Ltd.