SPINE Volume 33, Number 9, pp 1028 –1033
©2008, Lippincott Williams & Wilkins
Psychometric Testing Confirms That the
Brazilian-Portuguese Adaptations, the Original
Versions of the Fear-Avoidance Beliefs
Questionnaire, and the Tampa Scale of
Kinesiophobia Have Similar Measurement Properties
Fabricio Soares de Souza, PT,* Cristiano da Silva Marinho, PT,*
Fabiano Botelho Siqueira, PT, MSc,† Christopher Gerard Maher, PT, PhD,‡
and Leonardo Oliveira Pena Costa, PT, MSc*‡
Study Design. Translation, cross-cultural adaptation,
and psychometric testing of 2 questionnaires.
Objective. The objectives of this study were to translate
and cross-culturally adapt the Fear-Avoidance Beliefs Ques-
tionnaire (FABQ) to Brazilian-Portuguese and to test the psy-
chometric properties of the Brazilian-Portuguese versions of
the FABQ and the Tampa Scale of Kinesiophobia (TSK).
Summary of Background Data. Self-report measures
of fear-avoidance have been widely used in clinical prac-
tice and in research. To date there is no Brazilian-Portu-
guese version of the FABQ and the Brazilian-Portuguese
TSK has not yet been comprehensively tested.
Methods. The FABQ was cross-culturally adapted after
the recommendations from the Guidelines for the process
of cross-cultural adaptation of self-report measures. The
Brazilian-Portuguese versions of the FABQ and the TSK
were tested for internal consistency, reproducibility, ceil-
ing and floor effects, construct validity, and internal and
external responsiveness.
Results. Both instruments yielded high values for inter-
nal consistency and reproducibility [(Cronbach’s ␣ FABQ ⫽
0.93 and TSK ⫽ 0.82) and (Intraclass Correlation Coefficient
FABQ ⫽ 0.96 and TSK ⫽ 0.93)]. No ceiling and floor effects
were detected in either questionnaire. The FABQ and TSK
were highly correlated (r ⫽ 0.86) and they were moderately
correlated with the pain numerical rating scale at baseline
(r ⫽ 0.42 and r ⫽ 0.43, respectively) showing good construct
validity. The TSK was shown to be more responsive than
the FABQ in all internal and external responsiveness
analyses.
From the *School of Physiotherapy, Pontifı́cia Universidade Católica
de Minas Gerais, Brazil; †School of Physiotherapy, Centro Universitá-
rio de Belo Horizonte, Brazil; and ‡Musculoskeletal Division, The
George Institute for International Health, Sydney, Australia.
Sources of support: Leonardo Costa is a PhD student supported by CAPES –
Ministério da Educação – Brazil and Pontifı́cia Universidade Católica de Mi-
nas Gerais, Brazil. Christopher Maher holds a research fellowship funded by
the National Health and Medical Research Council of Australia.
Acknowledgment date: October 29, 2007. Revision date: November
28, 2007. Acceptance date: December 3, 2007.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
The study design, procedures, and informed consent were approved by the
Pontifı́cia Universidade Católica de Minas Gerais Ethics Committee.
Address correspondence and reprint requests to Leonardo Oliveira Pena
Costa, PT, MSc, Back Pain Research Group, School of Physiotherapy, The
University of Sydney, East Street Lidcombe, NSW 2141, Australia; E-mail:
lcos3060@gmail.com
1028
Conclusion. Both the Brazilian-Portuguese versions
of the FABQ and the TSK are equally useful in terms of
description and identification of patients with fear-
avoidance behavior; however, in situations that clini-
cians or researchers aimed to use fear-avoidance as a
follow-up measurement for treatment outcomes it
seems that the TSK is the better option due to its better
capacity to identify change over time.
Key words: fear-avoidance, kinesiophobia, low back
pain, reliability, validity, responsiveness, cross-cultural
adaptation. Spine 2008;33:1028 –1033
Fear-avoidance, which refers to the avoidance of move-
ments or activities based on fear, has been suggested to
be an important predictor of poor outcomes in patients
with chronic low back pain.1 It seems that early identi-
fication of patients with high levels of fear-avoidance is
crucial in terms of management; with early identification
and appropriate intervention it is possible to decrease the
risk of chronicity in these patients.2 The assessment of
fear-avoidance can be performed by psychophysiological
methods,3 by observational methods4 or by self-report
measurements.5 From those forms of assessment, the
self-report ones have the best combination in terms of
practicality, costs, reliability and validity and for those
reasons fear-avoidance questionnaires have being largely
used not only in clinical practice but also in research
studies.
Two widely used fear-avoidance questionnaires are
the Fear-Avoidance Beliefs Questionnaire (FABQ)6 and
the Tampa Scale of Kinesiophobia (TSK).5 The FABQ
focuses on the patient’s beliefs about how work and
physical activity (PA) would affect his/her low back pain.
The FABQ consists of 16 items and is divided into 2 sub-
scales, fear-avoidance beliefs about PA (FABQ-PA) and
fear avoidance beliefs about work (FABQ-Work). Each
item is provided with a 7-point Likert scale ranging from
“completely disagree” to “completely agree” and the score
system ranges from 0 to 96 points, the higher the score, the
higher are the fear-avoidance beliefs. The TSK is a 17-item
questionnaire that is aimed at the assessment of fear of
(re)injury due to movement. Each item is provided with a
4-point Likert scale ranging from “strongly agree” to
“strongly disagree” and the score system ranges from 17 to
 Brazilian Portuguese FABQ and TSK • de Souza et al 1029

68 points, and similarly to the FABQ, the higher the score, According to the “Quality criteria for measurement prop-
the higher the fear of movement. erties of health status questionnaires”13 it is necessary to enrol
The cross-cultural adaptation of questionnaires is the at least 50 participants for construct validity, reliability, and
first step to allow comparisons of different populations. ceiling/floor effects analyses. Therefore, 50 patients were re-
cruited for the study.
A number of reasons justify the need for high-quality
The patients completed the FABQ, the TSK and an 11-point
adaptations of relevant questionnaires: firstly, with Global Perceived Effect scale (GPE) (ranging from ⫺5 to ⫹5,
properly adapted questionnaires it will be possible to being ⫺5 as “vastly worse” and ⫹5 as “completely recovered”)
stop the exclusion of non-English speakers from ran- at baseline (as soon as the patients came to the clinics), 24-
domized controlled trials, secondly it will be easier to hours later (for test-retest reliability), and after 4 weeks of
pool data in systematic reviews, and finally it will allow treatment or discharge (for responsiveness).
researchers and clinicians to examine patients’ health The study design, procedures, and informed consent proto-
status in a broader spectrum of people, permitting the col were approved by the Catholic University of Minas Gerais
exchange of information across cultural and linguistic Ethics Committee.
barriers. A recent systematic review of cross-cultural Analysis
adaptations of self-report outcome measures for low Further tests were conducted on the psychometric properties of
back pain7 patients reveals that only the functional the adapted questionnaires. A list of the tests follows:
status questionnaires (the Roland Morris Disability
1. Internal Consistency (homogeneity) was evaluated using
Questionnaire,8,9 the Functional Rating Index,9 and
Cronbach’s ␣ and ␣“if item deleted”; Cronbach’s ␣ is
the Oswestry Disability Index10) have been translated considered adequate between 0.70 and 0.95.13
to Brazilian-Portuguese language and so far no fear- 2. Reproducibility was tested in a test-retest design and was
avoidance related questionnaire has been both evaluated using the Intraclass Correlation Coefficient
adapted and fully psychometrically tested in a Brazil-
ian population. There is an existing Brazilian- Table 1. Characteristics of Study Participants
Portuguese version of the TSK that was properly cross-
culturally adapted but only psychometrically tested by Variable All Participants Mean*
Rasch analysis.11 Therefore the objectives of this study Gender
were to cross-culturally adapt the FABQ and to test Male 23 (46.0)
the psychometric characteristics of the Brazilian- Female 75 (54.0)
Age (yr) 45.9 (12)
Portuguese versions of the FABQ and the TSK. Low back pain duration (wk) 5.42 (3.35)
Weight (kg) 71.2 (11.9)
Methods Height (m) 1.67 (0.1)
Pain NRS (0–10) at baseline 3.9 (0.78)
Overview of Study Design Pain interference scale (1–4) at baseline 3.26 (0.92)
The study was performed in 2 stages: the first stage was the Educational level
translation and cross-cultural adaptation of the FABQ; the sec- School certificate 5 (3.6)
ond stage was a study testing the psychometric properties of the Higher school certificate 3 (2.1)
Trade certificate 7 (5.0)
Brazilian-Portuguese FABQ and TSK. At the university 1 (0.7)
Bachelor degree 15 (10.7)
Translation and Cross-Cultural Adaptation Postgraduate degree 11 (7.9)
The cross-cultural adaptation was performed in accordance Other 8 (5.7)
with the Guidelines for the process of cross-cultural adaptation Marital status
Single 12 (24.0)
of self report measure12 as follows:
Married 35 (70.0)
Divorced 1 (2.0)
1. Initial translation: Two independent translators trans-
Widow 2 (4.0)
lated the FABQ from English to Brazilian-Portuguese. Working situation
2. Synthesis of the translations: After discussion, the 2 Yes 36 (72)
translators produced a consensus version of the FABQ. No 14 (28)
3. Back translation: Two new translators without a health Previous spinal surgery
Yes 0
sciences background independently back-translated the No 50 (100)
consensus version of the Brazilian-Portuguese FABQ Self-report fitness level
into English. Active 13 (26)
4. An expert committee reviewed all translations and dis- Sedentary 37 (74)
Self-report health status
cussed with the original translators possible discrepan-
Excellent 9 (18)
cies, and developed the final FABQ version to be tested in Very good 12 (24)
Brazil. Good 13 (26)
Fair 15 (30)
Testing Psychometric Properties Poor 1 (2)
This stage was performed on patients recruited from different Religion
Catholic 44 (95.7)
physiotherapy clinics (public and private) in Brazil, with the
Presbyterian 5 (3.6)
following inclusion criteria: presence of acute, subacute or Others 1 (0.7)
chronic nonspecific low back pain (NSLBP), able to speak and
*Continuous data are mean (SD), categorical data are N (%).
read Portuguese and aged between 18 and 80 years.
1030 Spine • Volume 33 • Number 9 • 2008
(ICC) (2.1). The ICC has been interpreted as follows: less
than 0.40 poor reliability, 0.40 to 0.75 moderate reliabil-
ity, 0.75 to 0.90 substantial, and greater than 0.90 ex-
cellent reliability.13
3. Construct validity was evaluated by correlating the Bra-
zilian-Portuguese FABQ, the Brazilian-Portuguese TSK,
an 11-point Pain Numerical Rating Scale (Pain NRS) and
the GPE at baseline using Pearson’s r; a score of 0.70
being recommended for instruments that measure the
same construct. When similar constructs are compared,
scores lower than 0.70 should be accepted.13
4. Potential ceiling and floor effects were measured by cal-
culating the percentage of patients indicating the mini-
mum and maximum possible scores in both question-
naires. Ceiling and floor effects are considered to be
present if more than 15% of respondents achieved the
Figure 1. Distribution of the TSK
and FABQ total scores at base-
line.
lowest or highest possible total score (ceiling and floor
effects are not related to individual items).13
5. Internal responsiveness of the Brazilian-Portuguese
FABQ and Brazilian-Portuguese TSK was assessed by
calculating the effect size (ES) with 84% confidence in-
tervals (CI). We calculated 84% CI for direct compari-
son of the ES. We chose 84% CI because nonoverlapping
84% CI are equivalent to a Z test of means at the 0.05
level.14 Responsiveness indicates the sensitivity of a
questionnaire to measure true change. Higher scores are
preferred.
6. External responsiveness of the Brazilian Portuguese
FABQ and TSK was assessed by (i) correlating GPE rates
to change scores of Brazilian Portuguese FABQ and Bra-
zilian Portuguese TSK and (ii) constructing ROC curves
using dichotomized GPE rates to categorize subjects as
 Brazilian Portuguese FABQ and TSK • de Souza et al 1031

Table 2. Internal Consistency and Reproducibility of the
FABQ (and Subscales) and the TSK
Internal Consistency (Cronbach’s Reproducibility
␣ ⫹ Range of “␣ if Item Deleted”) (ICC ⫹ 95% CI)
FABQ 0.93 (0.92–0.93) 0.96 (0.94–0.98)
FABQ-Work 0.82 (0.73–0.82) 0.86 (0.77–0.92)
FABQ-PA 0.94 (0.93–0.94) 0.97 (0.95–0.98)
TSK 0.82 (0.87–0.89) 0.93 (0.87–0.96)
“improved” and “not improved.” We defined 2 different
GPE cut-offs to categorize improvement, those cut-offs
were: patients who scored more than 3 points and pa-
tients who score more than 4 points. The analysis is
based on the area under the curve (AUC) and values of at
least 0.70 are considered responsive.13 We compared the
responsiveness of the paired AUC values using DeLong’s
method.15
The data were checked by 2 authors (F.S.S. and C.S.M.) before
the analyses.
Results
A total of 50 eligible patients were recruited and an-
swered all questionnaires at all 3 time points, being 29
patients with acute low back pain (from onset of symp-
toms to 6 weeks duration), 18 patients with subacute low
back pain (from 6 to 12 weeks duration), and 3 patients
with chronic low back pain (more than 12 weeks dura-
tion). Table 1 shows the characteristics of the study par-
ticipants. The distribution of scores of both question-
naires at baseline is described in Figure 1.
Both the FABQ (and subscales) and the TSK demon-
strated excellent internal consistency by achieving high
Cronbach’s ␣ values. The “alpha if item deleted” analy-
sis showed that no individual items from both instru-
ments are more relevant or redundant than the others.
Additionally, the reliability values ranged from substan-
tial (for the FABQ-Work scale) to excellent (for the
FABQ, the FABQ-PA scale, and the TSK) (Table 2).
There were no ceiling or floor effects for the FABQ
and TSK total scores; none of the participants achieved
the highest possible score on either of the 2 question-
naires and just 1 patient (2%) achieved the lowest score
of the TSK.
A high correlation between the FABQ and its sub-
scales and the TSK was found, both instruments and
the Pain NRS correlate moderately, however, neither
the FABQ (and its subscales) nor the TSK correlate
with the GPE (Table 3).
The FABQ and TSK had similar levels of internal re-
sponsiveness. The ES (84% CI) for the FABQ was ⫺0.18
(84% CI: ⫺0.09 to 0.02), the FABQ-work ES ⫽ ⫺0.04
(84% CI: ⫺0.15 to 0.07), the FABQ-PA ES ⫽ ⫺0.04 (84%
CI: ⫺0.08 to 0.01), and the TSK ES ⫽ ⫺0.07 (84% CI:
⫺0.18 to 0.04).
The levels of external responsiveness were consis-
tently higher in favor of the TSK compared with the
FABQ and its subscales. The TSK changed scores were
moderately correlated with the GPE change scores [r ⫽
⫺0.46 (P ⬍ 0.01)]; however, nonsignificant correlations
between the change scores of the FABQ and its subscales
and GPE change scores were not observed [FABQ total
score r ⫽ 0.23 (P ⫽ 0.10), FABQ-Work r ⫽ 0.27 (P ⫽
0.6), and FABQ-PA r ⫽ 0.15 (P ⫽ 0.3)]. The AUC values
for the TSK were significantly higher than the FABQ and
its subscales, regardless of the GPE cut-off chosen for
improvement (Table 4).
Discussion
This study aimed to cross-culturally adapt the Brazil-
ian-Portuguese version of the FABQ and to test the
psychometric properties of the Brazilian-Portuguese
versions of the FABQ and the TSK in patients with low
back pain presenting to physiotherapy clinics in Brazil.
Our results suggest that both questionnaires are reli-
able and valid for the measurement of fear-avoidance
in patients with low back pain, making them suitable
for use in clinical practice and also for research pur-
poses. We found that similarly to the original ver-
sions,5,6 both questionnaires achieved excellent levels
of homogeneity (i.e., the items are measuring the same
construct without being redundant), showing that all
items of the Brazilian-Portuguese versions of the
FABQ and the TSK are relevant and therefore the
structure and the scoring system match the original
English versions. This result supports the use of the
original and adapted questionnaires in cross-cultural
research. The Brazilian-Portuguese versions were also
shown to be highly reliable with the ICC scores falling
into the excellent reliability band of 0.70 to 0.95. We
are aware that the test-retest interval of 24 hours could
overestimate our reliability results due to recall from

Table 3. Correlations Among the FABQ (and Its Subscales), the TSK, the GPE, and Pain NRS at Baseline
FABQ Total Score FABQ-Work FABQ-Physical Activity TSK GPE Pain NRS

FABQ total score 1 0.72* 0.96* 0.86* 0.19 0.42*

FABQ-Work 0.72* 1 0.50* 0.70* 0.06 0.40*
FABQ-PA 0.96* 0.50* 1 0.79* 0.21 0.36*
TSK 0.86* 0.70* 0.79* 1 0.05 0.43*
GPE 0.19 0.06 0.21 0.05 1 ⫺0.07
Pain NRS 0.42* 0.40* 0.37* 0.43* ⫺0.07 1
*P ⬍ 0.01.
1032 Spine • Volume 33 • Number 9 • 2008
Table 4. Comparison of the Area Under the Curve for the
TSK Versus the FABQ
AUC Cut-Off 3 P AUC Cut-Off 4
FABQ 0.64 0.64
X 0.0011
TSK 0.77 0.74
FABQ-Work 0.50 0.58
X 0.0002
TSK 0.77 0.74
FABQ-PA 0.63 0.64
X 0.0006
TSK 0.77 0.74
P values are from DeLong’s test of paired AUC values.15
the first measurement, on the other hand this was the
only way to guarantee that the patients’ status were
stable over the test-retest period.
To our knowledge, there is no “gold standard” mea-
sure of fear-avoidance and therefore it is not possible to
assess criterion validity, however, the high correlations
between the TSK, the FABQ (and its subscales) and the
moderate correlations among the TSK, the FABQ (and
its subscales), and the pain NRS provide sufficient sup-
port for the construct validity of both questionnaires by
confirming our hypothesis of positive correlations
among those instruments. No correlation between both
questionnaires and the baseline values of the GPE was
found.
Both internal and external responsiveness were
checked in a test-retest design with a 4-week interval,
with the patients receiving intervention during this pe-
riod. We would expect that the patients will improve
for a number of reasons such as effects from the inter-
vention, placebo effects, natural history, regression to
the mean and “polite patients.”16 We found an ES of
0.50 (84% CI: ⫺2.80 to 2.34) for the GPE, however,
neither the FABQ (and its subscales) nor the TSK
scores improved as much. The interventions were de-
livered pragmatically according to the physiothera-
pists’ preferences and we did not control if the patients
received any specific intervention in regards to fear-
avoidance and maybe this issue can explain why the
patients improved in the GPE but not in the fear-
related instruments. We analyzed external responsive-
ness by correlating GPE rates to the change scores of
Brazilian-Portuguese FABQ and Brazilian-Portuguese
TSK and by constructing ROC curves using dichoto-
mized GPE rates to categorize subjects as “improved”
and “not improved.” We found that the TSK was con-
sistently more responsive than the FABQ (and its sub-
scales) in all tests for external responsiveness by
achieving moderate correlations with the GPEs change
scores (fact that were not yielded by the FABQ and its
subscales) and also by acceptable AUC values above
the benchmark of 0.70.13 This lower level of respon-
siveness of the FABQ was also found in the French17
and Swiss-German18 versions.
The results from this study demonstrate that both the
Brazilian-Portuguese version of the FABQ and the TSK
are reliable and valid measures to be used by Brazilian
P
health care providers and in research projects. Both ver-
sions are equally useful in terms of description and iden-
0.0191 tification of patients with fear-avoidance behavior; how-
ever, in situations where clinicians or researchers intend
0.0028 to use fear-avoidance as a follow-up measurement for
treatment outcomes, it seems that the TSK is the better
0.0416
option due to its better capacity to identify change over
the time.
Key Points
● A Brazilian-Portuguese version of the FABQ was
cross-culturally adapted according to recom-
mended guidelines.
● The Brazilian-Portuguese versions of the FABQ
and TSK are highly reliable and valid, similarly to
the original English versions.
● The Brazilian-Portuguese version of the TSK was
shown to be more responsive than the FABQ and
this must be taken in consideration for clinicians
and researches when choosing the appropriate in-
strument for measuring fear-avoidance.
● It is possible now to perform cultural compari-
sons from studies performed in Brazil with regard
to fear avoidance.
Acknowledgments
The authors thank Paulo Ferreira, Todd Irwin Marshall,
and Giovanni Pozzi for the translation procedures.
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