The fear avoidance model disentangled: improving the clinical utility of the fear avoidance model

Background: The model of fear avoidance proposes that fear of movement in back pain patients is an obstacle to recovery and leads over time to increased disability. Therefore, fear of movement should be targeted explicitly by interventions

Accepted Manuscript Cognitive and affective reassurance and patient outcomes in primary care: a systematic review Cognitive and affective reassurance and patient outcomes in primary care: a systematic review

Abstract In the context of uncertainty about aetiology and prognosis, good clinical practice commonly recommends both affective (creating rapport, showing empathy) and cognitive reassurance (providing explanations and education) to increase self-management in groups with non-specific pain conditions. The specific impact of each of these components in reference to patients' outcomes has not been studied. This review aimed to systematically evaluate the evidence from prospective cohorts in primary care that measured patient-practitioner interactions with reference to patient outcomes. We carried out a systematic literature search and appraisal of study methodology. We extracted measures of affective and cognitive reassurance in consultations and their associations with consultation-exit and follow up measures of patients' outcomes. We identified 16 studies from 16,059 abstracts. Eight studies were judged to be high in methodological quality. Pooling could not be achieved due to heterogeneity of samples and measures. Affective reassurance showed inconsistent findings with consultation exit outcomes. In three high-methodology studies, an association was found between affective reassurance and higher symptom burden and less improvement at follow up. Cognitive reassurance was associated with higher satisfaction and enablement and reduced concerns directly after the consultations in eight studies; with improvement in symptoms at follow up in seven studies; and with reduced health care utilization in three studies. Despite limitations, there is support for the notion that cognitive reassurance is more beneficial than affective reassurance. We present a tentative model based on these findings and propose priorities for future research