Researchers develop a tool to assess fear avoidance after concussion
By Zoe Marquis. This article was initially published in the 1/29/26 Edition of our Concussion Update newsletter; please consider subscribing.
Researchers Liam J. Sherwood et al. recently developed the Fear Avoidance after Concussion Tool (FACT), the first validated patient-reported outcome measure for evaluating fear avoidance following concussion. Fear avoidance behavior refers to a patient’s tendency to avoid activities or situations associated with their concussion or exacerbation of their symptoms out of fear, and it is recognized as a risk factor for persisting symptoms after concussion. Published in BMJ Open Sports and Exercise Medicine, FACT includes 28 items that patients rate on a scale of 0 (strongly disagree) to 3 (strongly agree). It has seven subscales (general, physical, psychological, hypervigilance, cognitive, social, work), and takes approximately 3.5 minutes to complete.
The researchers say that early recognition of fear avoidance behavior can allow clinicians to intervene earlier in the treatment process and reduce the risk of persisting symptoms after concussion. “Interventions, such as early education, and targeting psychological drivers of behaviour, have been shown to improve the prognosis of persisting symptoms. These interventions aim to empower the individual to self-manage and control their condition, reducing the negative influence that fear avoidance behaviour may have on recovery.”
Click here to access a copy of FACT itself, provided to us by lead author Liam Sherwood, BSc, MSc.
FACT was developed through a rigorous three-stage process based on COSMIN guidelines (COnsensus-based Standards for the selection of health Measurement INstruments) for content validity. The process involved semi-structured interviews with patients and professionals to generate an initial list of items; review by professionals to ensure relevance, comprehensibility, and comprehensiveness from a professional perspective; and interviews with patients to account for the patient perspective. In the first phase of the tool’s development, seven patients with lived experience of concussion and seven professionals considered experts in concussion management were interviewed to generate a total of 119 initial items. In phase two, 38 international experts were asked to review the items and rate each for relevance and comprehensibility. They were also asked if the overall tool was comprehensive or if additional items were needed. The researchers made revisions based on these responses, and, to ensure the tool met participants’ preference for length, only the top four most relevant items in each domain were included in the final tool. In phase three, ten patients were interviewed to give final feedback on FACT.
Thus, FACT satisfies content validation criteria and balances both patient and professional perspectives. The researchers note that there are a few other important measurement properties that were not evaluated in this study, but are currently being studied. While FACT has met content validity criteria, it still needs to be assessed for construct validity (a measure of whether fear avoidance exists as a consistent characteristic), internal consistency (a measure of how well each item measures fear avoidance), and reliability (a measure of whether the tool consistently produces similar results in similar situations). However, having a content-validated tool for assessing fear avoidance after concussion is an important step towards reducing the risk of persisting symptoms after concussion and supporting patients in their recovery.
