757387

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SMO0010.1177/2050312118757387SAGE Open MedicineAlhowimel et al.

SAGE Open Medicine

Systematic Review

SAGE Open Medicine

Psychosocial factors associated with Volume 6: 1­–8

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DOI: 10.1177/2050312118757387
https://doi.org/10.1177/2050312118757387

chronic low back pain patients treated by journals.sagepub.com/home/smo

physiotherapist: A systematic review

Ahmed Alhowimel1,2, Mazyad AlOtaibi1,2, Kathryn Radford2

and Neil Coulson2

Abstract
Background: Almost 80% of people have low back pain at least once in their life. Clinical guidelines emphasize the
use of conservative physiotherapy and the importance of staying active. While the psychological factors predicting poor
recovery following surgical intervention are understood, the psychosocial factors associated with poor outcomes following
physiotherapy have yet to be identified.
Methods: Electronic searches of PubMed, Medline, CINAHL, PsycINFO and EBSCO were conducted using terms relating
to psychosocial factors, chronic low back pain, disability and physiotherapy. Papers examining the relationship between
psychosocial factors and pain and disability outcomes following physiotherapy were included. Two reviewers selected,
appraised and extracted studies independently.
Results: In total, 10 observational studies were identified that suggested an association between fear of movement,
depression, self-efficacy and catastrophizing in modifying pain and disability outcomes following physiotherapy.
Discussion: Although limited by methodological shortcomings of included studies, and heterogeneity of physiotherapy
interventions and measures of disability and psychosocial outcomes, the findings are consistent with other research in
the context of back pain and physiotherapy, which suggest an association between psychosocial factors, including fear of
movement, catastrophizing and self-efficacy and pain and disability outcomes in chronic low back pain patients treated by
physiotherapist. However, a direct relationship cannot be concluded from this study.
Conclusion: Findings suggest an association between psychosocial factors, including fear of movement, catastrophizing and
self-efficacy and pain and disability outcomes in chronic low back pain patients treated by physiotherapist, which warrants
further study.

Keywords
Chronic low back pain, outcomes, physiotherapy, psychosocial

Date received: 29 May 2017; accepted: 15 January 2018

Introduction
Low back pain (LBP) is one of the most predominant muscu-
loskeletal disorders in industrialized societies.1,2 Although 1Department of Physical Therapy and Health Rehabilitation, Prince Sattam

the prevalence of LBP is high, with up to 80% of people Bin Abdulaziz University, Al Kharj, Saudi Arabia
2Division of Rehabilitation and Ageing, School of Medicine, University of
reporting at least one episode during their lifetime,3 most Nottingham, Nottingham, UK
people recover within 1 month.4 However, some 10%–40%
of all LBP patients go on to develop chronic symptoms and Corresponding author:
Ahmed Alhowimel, Department of Physical Therapy and Health
suffer some form of disability. Rehabilitation, Prince Sattam Bin Abdulaziz University, 16278 Al Kharj,
While there are many different approaches used in the Saudi Arabia.
treatment of chronic low back pain (CLBP), there is Email: ahmed.alhowimel@nottingham.ac.uk

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2 SAGE Open Medicine

consensus among clinical guidelines on the promotion of and conformed to the PRISMA (Preferred Reporting Items
conservative rather than surgical intervention.5,6 Conservative for Systematic Reviews and Meta-Analyses) statement.14
treatment often equates to a physiotherapy-based interven-
tion, which includes exercise and education.
Eligibility criteria
The outcomes of physiotherapy intervention vary, with
pain and disability the most frequently measured.7 Several Primary research studies published in the English language
factors could potentially moderate these outcomes. In a sec- and that met the inclusion criteria were included in the
ondary analysis of data from a prospective cohort of a mixed review. There was no restriction on the study design or the
group of patients with CLBP and acute LBP (n = 111) receiv- methodological quality.
ing outpatient physiotherapy for LBP, patients’ 6-month
outcomes, assessed on a range of psychological, pain and
Inclusion criteria
disability measures, were compared between patients who
had recovered (12.6%) and those who had not. At 6 months, Inclusion criteria were as follows:
non-recovered patients had higher fear avoidance, kinesio-
phobia and depressive symptoms (all p < 0.001) compared •• Age between 18 and 65 years.
with recovered patients. From discriminant function analy- •• CLBP of duration ≥3 months.
sis, fear avoidance, kinesiophobia and depressive symptoms •• Studies with mixed patient groups (acute and chronic)
were found to make significant unique contributions to the were included if separate analysis of chronic patients
prediction of recovery status following physiotherapy.8 In was reported.
addition, psychosocial factors have been reported to influ- •• No pathoanatomical diagnosis (e.g. stenosis,
ence outcomes in primary care settings and after fracture).
surgery.9,10 •• Physiotherapy intervention, either alone or as part of a
More recently, attention has turned towards identifying and multidisciplinary team.
examining the contribution of psychological factors such as •• Reporting psychosocial outcome measure (fear, anxi-
fear of movement and catastrophizing to recovery in people ety etc.) and correlation with pain and/or disability
with CLBP. In a review of 25 prospective cohort studies, Pincus after physiotherapy intervention.
et al.11 reported that fear avoidance, depression and catastro-
phizing were predictive of progression from acute LBP to Primary outcome measures of the included studies had to
CLBP. Likewise, in a systematic review, Wertli et al.12 high- include the following:
lighted the moderating effect of fear-avoidance beliefs on treat-
ment efficacy in LBP patients and suggested that the presence •• Pain (e.g. visual analogue scale (VAS), McGill Pain
of fear-avoidance beliefs is associated with poor recovery. Questionnaire);
While there is evidence of multiple prognostic psychoso- •• Disability (e.g. Roland Morris, Oswestry Disability
cial factors associated with LBP recovery, this does not dis- index);
tinguish clearly between CLBP and acute LBP. Moreover, •• Psychosocial outcome measures (e.g. Fear-Avoidance
there has been no systematic review of the evidence explor- Beliefs Questionnaire).
ing the association between psychosocial factors and pain
and disability outcomes specifically following
Information source
physiotherapy.13
Understanding more about the relationship between psy- Reviewers searched academic databases from inception to 17
chosocial factors and physiotherapy could inform a more March 2016. In addition, the reference sections of the extracted
stratified physiotherapy intervention targeting psychosocial articles were manually searched for any articles missed by the
impairments in CLBP patients. electronic search. Academic databases, including PubMed,
Medline, CINAHL, PsycINFO and EBSCO, were used to
extract relevant studies. Two independent reviewers (A.H. and
Aim M.A.) conducted the electronic search. Keywords facilitated
The aim of this systematic review was to identify the psy- the search process and included the following: chronic low
chosocial factors associated with pain and/or disability in back pain, low back pain, psychosocial predictors, disability,
CLBP patients treated by physiotherapist. psychosocial, catastrophizing, depression, worry, fear avoid-
ance and physiotherapy. These keywords were combined
using the Boolean operators ‘AND’ and ‘OR’ (Appendix 1).
Methods/design
Protocol and registration Study selection
The systematic review protocol was registered on Two reviewers (A.A. and M.A.) independently screened the
PROSPERO (registration number 2016: CRD42016034132) titles and abstracts of all studies retrieved from the database
Alhowimel et al. 3

Table 1.  Characteristics of the included studies.

Study origin Sample size (n) Age, mean (SD) Baseline pain Follow-up
severity, VAS (weeks)
Ayre and Tyson16 Australia 121 39.42 (9.5) 5.45 0
Briggs et al.17 Australia 117 39.7 (12.4) 4.25 0
Cougot et al.18 France 217 41.33 (9.5) 3.99 104
Elfving et al.19 Sweden 149 48.56 (NA) NA 0
Ferreira and Pereira20 Portugal 203 48.75 (NA) NA 5
Thomas et al.21 France 50 50.2 (11.4) 4.5 0
Woby et al.22 UK 83 41 (10) 4 8
Woby et al.23 UK 102 43.9 (11.7) 4.4 8
Woby et al.24 UK 166 44.4 (11.4) 4 8
Rainville et al.25 USA 72 37 (NA) 7 7

VAS: visual analogue scale; SD: standard deviation; NA: not applicable.

search. Studies without psychosocial factors and physiother- Quality assessment

apy or rehabilitation keywords in the title were excluded, and
if the abstract clearly stated no physiotherapy was used or The search strategy did not limit study design and all the
that only acute back pain patients were studied, the study included studies were either cross-sectional or prospective
was excluded. If there was uncertainty about whether a paper cohort studies. Thus, the quality of evidence and strength of
should be excluded based on the abstract, the full-text copy recommendation was assessed using the Quality Assessment
of the article was retrieved and reviewed. Any disagreements Tool for Observational Cohort and Cross-Sectional Studies,
were resolved by discussing the study outcomes and other developed by the National Institutes of Health.15 The tool
measures with a third reviewer (either K.R. or N.C.). Records consists of 14 criteria and reviewers decide whether the cri-
of studies excluded from the review were kept and reasons teria exist or not. The assessment was carried out by two
for exclusion noted. independent reviewers (A.A. and M.A.).

Summary of measures
Data collection process
The association between fear avoidance, catastrophizing,
The included studies passed through a data extraction pro- self-efficacy, depression and days off work and pain and/or
cess in which two reviewers (A.A. and M.A.) indepen- disability outcomes was reported in accordance with the
dently extracted the following information: title and original study statistical analysis.
authors, objectives and study design, start and end dates,
duration of study participation, description of the popula- Results
tion from which the participants were drawn, study setting,
inclusion and exclusion criteria, methods of recruiting the The PRISMA chart (Figure 1) shows the process of study
study participants, the number and demographic character- selection. A total of 10 studies met the inclusion criteria after
istics of participants, severity of CLBP, participant comor- the full-text screening (see Table 1). The most common rea-
bidities and study outcomes, conclusions and limitations sons for exclusion by abstract screening were a lack of a
reported by authors. physiotherapy intervention or psychosocial outcome meas-
ure. The most frequent reason for excluding full-text studies
was a lack of separate data for CLBP in studies involving
Risk of bias in individual studies mixed CLBP and acute LBP patients.
Most included studies (six) were prospective cohort
Considering the aim was to identify prognostic psychoso- designs and four were cross-sectional. The total number of
cial factors, the risk of bias in studies included in the review participants was 1280. Mean age (standard deviation (SD))
was assessed by two reviewers (A.A. and M.A.) indepen- across the studies was 44.0 ± 4.7 years with a marginally
dently using the Quality in Prognostic Studies (QUIPS) tool higher proportion of women (51%). Average pain intensity
for reporting the risk of bias in prognostic systematic measured at the initial assessment before physiotherapy
reviews. The tool has six domains covering study participa- commences by VAS was 4.7 ± 1.0 from all included studies
tion, attrition, prognostic factor measurement, outcome (Table 1). Average percentage dropout from all included
measurement, confounding, statistical analysis and studies was 12%. All of the prospective cohort studies
reporting. reported measurements before and after physiotherapy
4 SAGE Open Medicine

Table 2.  Description of the included studies.

Author Outcome measures Results Conclusions

Type of study
Study objective
Thomas et al.21 Correlation between Roland Morris Back Pain Psychosocial factors are
Cross-sectional Disability Questionnaire and strongly associated with
To evaluate fear beliefs • DALLAS Pain Questionnaire – daily living R = 0.52; p = 0.0001 disability and altered quality of
and catastrophizing • DALLAS Pain Questionnaire – social R = 0.43; p = 0.0001 life in chronic low back pain
before starting • Pain Catastrophizing Scale (PCS) R = 0.464; p = 0.0008 (CLBP) patients
physiotherapy • Tampa Scale for Kinesiophobia (TSK) R = 0.060; p = 0.0001
• Hospital anxiety and depression scale R = 0.047; p = 0.0006
Woby et al.24 Change in disability as an outcome and changes Education in fear
Prospective cohort in below outcomes as predictors: of movement and
To investigate whether • Tampa Scale for Kinesiophobia (TSK) t = 2.33; p < 0.001 catastrophizing and increases
CLBP patients display • Functional subscale of the Chronic Pain Self- t = −3.08 (p < 0.001) in functional self-efficacy are
changes in cognitive level Efficacy Scale t = 0.97 (p < 0.001) predictors of function
after a physiotherapy • Catastrophizing subscale of Coping Strategy
programme Questionnaire (CSQ)
Cougot et al.18 The positive prognostic factors for return to Failure to return to work
Prospective cohort work are as follows: after 2 years follow-up
To study the prognostic • DALLAS Pain Questionnaire – anxiety and OR 0.97; 95% CI is associated with high
factors influencing depression OR 0.96; 95% CI depression level, low quality
return to work in CLBP • DALLAS Pain Questionnaire – daily activities OR 0.98; 95% CI of life and more than 112 sick
receiving rehabilitation • DALLAS Pain Questionnaire – social OR 1.00; 95% CI leave days
• Number of days missed
Ferreira and Pereira20 Correlation between quality of life and The quality of life of CLBP
Cross-sectional functional ability: patients is associated with
To study the mediating • Short-form general health survey with t = −8.013; p < 0.01 high disability and high
role of psychological Roland Morris Back Pain Disability depression
variables that Questionnaire (RMDQ)
discriminate low and Correlation between quality of life and anxiety:
high disability • Short-form general health survey with
Hospital Anxiety and Depression Scale t = −9.99; p < 0.01
(HADS)
Briggs et al.17 High disability scores correlated with LBP-related beliefs and
Prospective cohort • Catastrophizing subscale of Coping Strategy r2 = 0.15; p = 0.003 behaviours, rather than
To explore the role of Questionnaire (CSQ) r2 = 0.07; p = 0.06 pain intensity and health
health literacy in relation • Fear-Avoidance Beliefs Questionnaire – r2 = 0.30; p < 0.001 literacy skills, were found to
to disability and beliefs work be important correlates of
• Fear-Avoidance Beliefs Questionnaire – disability related to LBP
activities
Elfving et al.19 Odd ration of High Roland Morris Disability This study indicates
Cross-sectional Questionnaire (RMDQ) is associated with the importance of
To study the • Pain Catastrophizing Scale (PCS) OR 6.5 and 5.8 physiotherapists measuring
relationship between • Tampa Scale for Kinesiophobia (TSK) compared with 1.1 in levels of fear-avoidance and
physical activity level and low disability; 95% CI pain catastrophizing
fear-avoidance beliefs OR 7.4 and 4.4
and catastrophizing compared with 1.1 in
low disability; 95% CI
Woby et al.23 Correlation between pain intensity measured by Standardized When self-efficacy is high,
Prospective cohort visual analogue scale (VAS) and a subscale of the β = 0.23; p < 0.05 elevated pain-related fear
To study the predictive Chronic Pain Self-Efficacy Scale Standardized might not lead to greater pain
role of self-efficacy in Correlation between pain-related fear measured β = 0.38; p < 0.01 and disability. However, in
pain and pain-related by Fear-Avoidance Beliefs Questionnaire instances where self-efficacy is
fear (FABQ) and a subscale of the Chronic Pain Self- low, elevated pain-related fear
Efficacy Scale is likely to lead to greater pain
and disability
Alhowimel et al. 5

Table 2. (Continued)
Author Outcome measures Results Conclusions
Type of study
Study objective
Woby et al.22 Change in pain intensity in relation to Reductions in fear-avoidance
Prospective cohort • Pain Catastrophizing Scale (PCS) t = 1.46; p < 0.05 beliefs about work and
To study the role of • Fear-Avoidance Beliefs Questionnaire t = 0.22; p < 0.01 physical activity, as well
patient adjustment to (FABQ) t = −1.26; p < 0.05 as increased perceptions
CLBP in relation to • Coping Strategy Questionnaire (CSQ) t = 1.05; p < 0.05 of control over pain were
their fear avoidance, Change in disability score in relation to: t = 3.46; p < 0.01 uniquely related to reductions
catastrophizing and • Pain Catastrophizing Scale (PCS) t = −1.96; p < 0.05 in disability
appraisal of control • Fear-Avoidance Beliefs Questionnaire
(FABQ)
• Coping Strategy Questionnaire (CSQ)
Ayre and Tyson16 Disability measured by Quebec Low Back Pain Self-efficacy explained 24%
Cross-sectional Disability Scale: β = 0.57; p < 0.05 of the variance in disability
To study the role of Pain Self-Efficacy Questionnaire β = 0.21; p < 0.01 scores, and fear avoidance
self-efficacy and fear in Fear-Avoidance Beliefs Questionnaire – work β = −0.07; p < 0.01 only a further 3.1%
disability outcomes Fear-Avoidance Beliefs Questionnaire – activity
Rainville et al.25 Correlation between Pain and Impairment PARIS score was not strongly
Prospective cohort Relationship Scale (PARIS) and correlated with depression
To investigate the • Pain intensity score 0.47; p < 0.01 and pain intensity measures
alteration of pain and • Beck Depression Inventory 0.46; p < 0.001
impairments beliefs
in functional-oriented
treatment of CLBP

intervention; only one study reported on follow-up beyond measures used were the Tampa Scale for Kinesiophobia
physiotherapy intervention.18 and the Fear-Avoidance Beliefs Questionnaire. Higher
fear-avoidance scale scores did not predict pain levels in
one study.23
Methodological quality and risk of bias
On application of the QUIPS bias assessment tool for prog-
nostic studies, the bias assessment of included studies Catastrophizing
showed low to moderate risk. The overall quality of the Pain catastrophizing as measured by the Pain Catastrophizing
included studies was ‘fair’ using the Quality Assessment Scale (PCS) correlated with disability levels in four
Tool for Observational and Cohort Studies, with 100% studies.17,19,21,24
agreement between the two assessors.
The included studies were heterogeneous in terms of
the nature of the physiotherapy intervention and utilized Self-efficacy
different outcome measures when reporting the relation- Self-efficacy, as measured by the functional subscale of the
ship between the intervention and the outcomes. Therefore, Chronic Pain Self-Efficacy Scale, was reported to predict
comparison between studies was only possible in terms of levels of pain-related disability and pain in three
the identified outcomes. An adapted cognitive behavioural studies.17,23,24
therapy approach was reported in four studies, a multidis-
ciplinary team approach to CLBP management was used in
one study, while the five remaining studies did not describe Depression and anxiety
the content of the physiotherapy intervention delivered.
An association between pain-related disability levels and
Four psychosocial factors were found to correlate with depression was reported in two studies,18,20 and in one
pain and disability outcomes. The outcome measures used study high depression and anxiety scores were found pre-
varied among the selected studies (Table 2). dictive of poor quality of life and failure to return to
work.20
Fear avoidance Anxiety, measured using the Hospital Anxiety and
Depression Scale, was reported in three studies18,20,21 and
Fear-avoidance factors were reported to influence disabil- found to be associated with high levels of disability and
ity scores in eight studies.16,17,19,21–24,25 The outcome pain.
6 SAGE Open Medicine

Figure 1.  Prisma flow chart.

Working days missed due to LBP These associations may have direct implications for man-
aging CLBP patients, especially those with low scores on
Correlations between the number of working days missed functional outcome measures. These results support the find-
due to LBP and disability levels and work outcomes, that is, ings of George and Beneciuk8 in a retrospective cohort study
return to work, were reported in two studies.17,18 of CLBP patients, in which pain intensity was found to be
predictive of treatment outcome.
Discussion They are also consistent with the findings of the systematic
review by Wertli et al.,12 who found that participants’ fear-
The aim of this systematic review was to identify psychoso- avoidance beliefs had a moderating effect on treatment effi-
cial factors associated with changes in pain and/or disability cacy. The most frequently reported association in this review
in CLBP patients treated by physiotherapist. was that between fear avoidance and physical disability.
Although the results suggesting a clear correlation between These findings strengthen the legitimacy of the fear-avoid-
these variables are inconclusive due to the broad scope of phys- ance model,26,27 which suggests that the presence of psychologi-
iotherapy and heterogeneity of included studies, the findings cal factors, such as fear of pain, catastrophization and depression
support an association between disability and levels of pain fol- after experiencing pain, leads to fear of movement, resulting in
lowing physiotherapist treatment and baseline psychosocial disuse and further disability. Fear-avoidance model elements
factors; the greater the level of disability and pain reported, the were associated with improvements in pain and disability out-
higher the scores in fear avoidance and catastrophizing. comes in people with CLBP treated by physiotherapist. Quality
Alhowimel et al. 7

of life was also associated with both higher disability and higher Declaration of conflicting interests
anxiety levels in people with CLBP. The author(s) declared no potential conflicts of interest with respect
Although the findings of this study highlight a positive to the research, authorship and/or publication of this article.
association between low levels of disability and pain inten-
sity at baseline and improvement following physiotherapist Ethical approval
treatment, a single-centre prospective study of 101 LBP
Ethical approval is not applicable since this is a systematic review
patients27 found that baseline disability scores were not pre-
study.
dictive of recovery. However, this was a sub-acute patient
with CLBP. Clearly more research is needed to clarify the
relationship between initial disability scores and physiother- Funding
apy outcomes in people with CLBP. The author(s) received no financial support for the research, author-
Several quality assessment tools have been used to evalu- ship and/or publication of this article.
ate observational studies.25 However, these tools lack valid-
ity and reliability.28 Therefore, further research is needed to Informed consent
develop a standardized and validated quality assessment tool
Informed consent is not applicable since this is a systematic review
for use in observational studies.
study.

Limitations Trial registration

The systematic review protocol was registered on PROSPERO
The term ‘physiotherapy’ was generic and not limited to spe-
(registration number 2016: CRD42016034132).
cific treatments. The interventions in included studies were
poorly described but ranged from individual exercise-based
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