Quantifying fear avoidance behaviors in people with concussion: A COSMIN-informed systematic review

Document Type

Journal Article

Publication Title

Journal of Orthopaedic & Sports Physical Therapy





First Page


Last Page


PubMed ID



Movement Science Media


School of Medical and Health Sciences / Nutrition and Health Innovation Research Institute


Australian Government Research Training Program


Sherwood, L. J., Korakakis, V., Mosler, A. B., Fortington, L., & Murphy, M. C. (2023). Quantifying fear avoidance behaviors in people with concussion: A COSMIN-informed systematic review. Journal of Orthopaedic & Sports Physical Therapy, 53(9), 540-565. https://doi.org/10.2519/jospt.2023.11685


t OBJECTIVE: The validity of existing fear avoidance behavior patient-reported outcome measures (PROMs) for concussion is unknown. This study aim to (1) identify PROMs that assess fear avoidance be havior in individuals with concussion and (2) asses the measurement properties of these PROMs. t DESIGN: A systematic review of outcome mea surement instruments using the COnsensus-base Standards for the selection of health Measureme INstruments (COSMIN) checklist. t LITERATURE SEARCH: We performed a systematic search of 7 databases. t STUDY SELECTION CRITERIA: Studies were included if they assessed fear avoidance behavior (eg, kinesiophobia or cogniphobia) in participants with concussion, occurring in all settings (eg, sport, falls, assaults). t DATA SYNTHESIS: Methodological quality of the PROMs was assessed using the COSMIN checklist, and the certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. t RESULTS: We identified 40 studies assessing fear avoidance. Four studies (n = 875 participants, representing 3 PROMs) were eligible for COSMIN assessment. Content validity for all PROMs was insufficient due to extreme risk of bias. The Fear Avoidance Short Form Scale demonstrated the greatest validity: moderate-certainty evidence for sufficient structural validity and internal consistency, and low-certainty evidence for measurement invariance. t CONCLUSION: Current PROMs for measuring fear avoidance behaviors in people with concussion have insufficient content validity and should be used with caution in research and clinical practice.



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