Back pain and low back pain can be a big problem for the individual and remains a challenging problem for the healthcare system. The focus on hack pain over the last few decades has been biomedical. Psychological factors such as fear avoidance and distress have been neglected. Distress is prevalent among patients with back pain and those who are distressed are at risk of developing chronic disability. The aim of this review was to investigate the occurrence of psychological outcome measures for distress and fear avoidance in patients with back pain and also what interventions were used to affect these factors. Literature research in PubMed, Medline, PEDro, PsycINFO and Cochrane was carried out for a period from 1994 to 2004. References were screened for 'randomized clinical trial'. Fifteen relevant trials were identified; seven of these were high quality and eight were low quality. There is strong evidence that behavioural therapy has an effect on psychological outcome measures for fear avoidance or distress. There is moderate evidence that physical training has an effect on psychological measures for fear avoidance or distress. Conclusions on whether other interventions are effective cannot be drawn from this material. Future research could determine if implementation of psychosocial risk assessment is feasible in daily clinical practice and if it leads to more effective management.

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