The intricate relationship amongst pain intensity, fear and avoidance
-
Johan W.S. Vlaeyen
1 Fear of an internal threat like pain causes avoidance of pain-provoking movements
Fear is an emotional response that occurs when the individual is directly threatened with a potentially life-threatening event, and the behavioural manifestation of fear usually is immediate escape from that event. Fear has been studied extensively in situations where there is an external threat, such as violence by another person or an animal. The automatic response is to attack or to escape the dangerous object and its location as fast as possible. The situation is somewhat different when the threat is coming from within the body, such as musculoskeletal, neuropathic or visceral pain, and from which escape is not possible. In the absence of an escape route, the only possibility is to prevent or avoid an increase of that pain sensation by staying immobilized or moving slowly and carefully. Such acute painful events are salient learning experiences. In most cases, the pain will diminish after a while, and the person might remember that just staying still or moving slowly is associated with less pain. As a result, this behavioural avoidance pattern is likely to be repeated in subsequent recurrences of pain or early signs of such a pain episode.
2 Avoidance of pain-provoking movements facilitates healing, but if continued after a healed injury may create abnormal and prolonged fear of pain and movement
There is a general agreement that the avoidance response is adaptive, and that it may facilitate the healing process. This line of thought is of course correct under the assumption that pain is a reflection of some lesion in the body. However, how do we know that a to-be-healed event has taken place in the first place, and similarly, how do we know when healing has occurred, and when the protective behaviours are not necessary anymore? Most individuals will use the pain experience as the most important source of information to infer some kind of physical anomaly, and the question is whether this inferential process is always accurate. Moreover, avoidance is a behavioural action that may interfere with or prevent other behaviours that facilitate daily life personal goal pursuit [1].The more avoidance behaviours, the more likely that the person feels disabled. In other words, fear of pain or pain-related stimuli (such as movements) will be associated with protective avoidance behaviours that initially maybe facilitate healing, but in the long run maintains disability. Also, avoidance behaviours may become habits that persist, also when fear has diminished. This is in fact the quintessence of the fear-avoidance model, introduced by Lethem et al., more than 30 years ago [2, 3], and later refined by others [4, 5, 6].
3 Treat pain-related fear in order to decrease risk of chronic disability
Since the introduction of the fear-avoidance model, numerous studies have examined the effects of pain-related fear on cognitive [7], brain [8] and motor function [9] in various pain patient groups. In order to summarize these findings, a recent meta-analysis convincingly showed that the relation between pain-related fear and disability is moderate to large in magnitude, and quite stable across demographic and pain characteristics [10]. The conclusion of that study was that pain-related fear might be an important target for treatments aimed at reducing pain-related disability.
4 Fear-avoidance may inflate the patient’s report of pain
However, there are reasons to believe that fear and avoidance behaviour also influence the report of pain. Several prospective studies revealed that fear of pain is a strong predictor of pain outcomes later on [11], although another study demonstrated that pain-related fear was found to be a consequence rather than an antecedent of pain severity [12]. These findings suggest a unique but intricate relationship between pain severity and pain-related fear, which is corroborated in several other studies as well [13].
5 Association between fear-avoidance and reported pain intensities
These and other findings must have inspired Emily Kroska who performed a meta-analysis with the aim to study the association between pain-related fear and pain intensity reports, published in this issue of the Scandinavian Journal of Pain [14]. The author performed an impressive amount of work, selecting 799 studies for consideration using keywords, and finally coding 118 studies for the current meta-analysis. She then calculated effect sizes, reflecting the strength of the associations found, using the correlation coefficients of the pain and fear-avoidance variables. Given that they are standardized (using Fisher’s Z transformations), these effect sizes have the advantage of direct comparison in different studies that utilized different variables and different scales of measurement of the same variable. The results are interesting, as the standardized correlations between the pain-related fear and pain intensity measures vary between 0.18 and 0.28, suggesting small-to-moderate positive association amongst these variables.
6 Motivational factors may influence fear-of-pain and avoidance
The reason why not stronger associations were found is not totally clear, but one possibility is that the presence of pain may not always be a reason to rise fear and to avoid activities. Fear is more likely to occur when the meaning attached to pain is negative, and when it threatens the sense of self [15]. In most of the studies that were included in Kroska’s meta-analysis [14], the motivational dimension of pain was not addressed, and this is a novel and emerging field in pain psychology [16]. Vice versa, reports of fearful beliefs and avoidance can persist as habits, also when pain has diminished. Interestingly, fear-avoidance beliefs have also been observed in healthy individuals [17].
7 Moderation analyses – cultural influences on fear-avoidance
Another interesting feature of Kroska’s study is the inclusion of moderation analyses, providing additional depth into the relationship between fear-avoidance and pain intensity [14]. Moderation analyses are usually conducted when the relationship between the variables of interest are rather weak to moderate, which is indeed the case here. In fact, moderation analyses consist of a statistical way to empirically derive subgroups of subjects who share features. This is one of the first meta-analyses in the pain field including “culture” as a moderator, using Hofstede’s dimensions of national culture (see [14, 18]). The results indicated that the association between fear-avoidance and pain intensity was stronger in cultures where individuals accept an unequal distribution of power in society, in cultures that value collectivist ideals, and in cultures where restraint is more important than short-term gratification [14]. Although this is an interesting and seldom researched topic, an unanswered question is what the moderation by culture actually means in the context of fear-avoidance and pain. The author did not formulate clear hypotheses, which is something that merits more thought. Also, and acknowledged by the author, even though Hofstede’s model is generally accepted, its validity has also been criticized, e.g. by McSweeney [18]. Some more work is necessary here.
8 Implications of the Kroska study results [14] on behavioural treatments of chronic pain
What are the implications of this meta-analytic review for behavioural treatments in chronic pain populations? Cognitive-behavioural therapy, and exposure-based treatments in particular, have shown to be successful in improving psychological and physical functioning among chronic pain patients [19]. The primary aim of these treatments is not the reduction of pain, but the restoration of daily functioning and the achievement of personal goal. Nevertheless, several studies clearly demonstrate that a successful exposure treatment can be associated with the reduction of self-reported pain severity, albeit with some delay [20, 21]. For example, den Hollander et al. [21], compared the effectiveness of exposure and treatment as usual in patients with complex regional pain syndrome (CRPS-I), and clearly demonstrated that the exposure treatment was superior not only in reducing pain-related fear, but also in reducing self-reported pain intensity. Typical for the exposure treatment provided to these patients is not just approaching activities in general, but approaching activities that are customized and geared towards individuals goals and personally valued activities. It is likely that experiencing the – by the patients almost forgotten-possibility to actually do what they value most in life, brought back meaningfulness. These results are reminiscent of one of the pioneering behaviourists Wilbert Fordyce’s sayings: “Pain patients would suffer less if they have something better to do” [22].
9 Concluding remark
In sum, Kroska’s work [14] is an important step in the understanding of the role of pain-related fear in the expression of pain in individuals with chronic pain, and it encourages us to scrutinize further some of the surprising and unexplained findings connected with the fear-avoidance model of pain [6].
DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2016.06.011.
References
[1] Crombez G, Lauwerier E, Goubert L, Van Damme S. Goal pursuit in individuals with chronic pain: a personal project analysis. Front Psychol 2016;7:966.Search in Google Scholar
[2] Lethem J, Slade PD, Troup JD, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception—I. Behav Res Ther 1983;21:401–8.Search in Google Scholar
[3] Philips HC. Avoidance behaviour and its role in sustaining chronic pain. Behav Res Ther 1987;25:273–9.Search in Google Scholar
[4] Asmundson GJ, Norton PJ, Norton GR. Beyond pain: the role of fear and avoidance in chronicity. Clin Psychol Rev 1999;19:97–119.Search in Google Scholar
[5] Simons LE, Kaczynski KJ. The Fear Avoidance model of chronic pain: examination for pediatric application. J Pain 2012;13:827–35.Search in Google Scholar
[6] Vlaeyen JW, Crombez G, Linton SJ. The fear-avoidance model of pain. Pain 2016;157:1588–9.Search in Google Scholar
[7] Gatzounis R, Schrooten MG, Crombez G, Vlaeyen JW. Interrupted by pain: an anatomy of pain-contingent activity interruptions. Pain 2014;155:1192–5.Search in Google Scholar
[8] Meier ML, Stampfli P, Vrana A, Humphreys BK, Seifritz E, Hotz-Boendermaker S. Neural correlates of fear of movement in patients with chronic low back pain vs. pain-free individuals. Front Hum Neurosci 2016;10:386.Search in Google Scholar
[9] Thomas JS, France CR. Pain-related fear is associated with avoidance of spinal motion during recovery from low back pain. Spine (Phila Pa 1976) 2007;32:E460–6.Search in Google Scholar
[10] Zale EL, Lange KL, Fields SA, Ditre JW. The relation between pain-related fear and disability: a meta-analysis. J Pain 2013;14:1019–30.Search in Google Scholar
[11] Archer KR, Seebach CL, Mathis SL, Riley 3rd LH, Wegener ST. Early postoperative fear of movement predicts pain, disability, and physical health six months after spinal surgery for degenerative conditions. Spine J 2014;14:759–67.Search in Google Scholar
[12] Gheldof EL, Crombez G, Van den Bussche E, Vinck J, Van Nieuwenhuyse A, Moens G, Mairiaux P, Vlaeyen JW. Pain-related fear predicts disability, but not pain severity: a path analytic approach of the fear-avoidance model. Euro J Pain 2010;14:e871–9.Search in Google Scholar
[13] Labrenz F, Icenhour A, Schlamann M, Forsting M, Bingel U, Elsenbruch S. From Pavlov to pain: how predictability affects the anticipation and processing of visceral pain in a fear conditioning paradigm. Neuroimage 2016;130:104–14.Search in Google Scholar
[14] Kroska EB. A meta-analysis of fear-avoidance and pain intensity: the paradox of chronic pain. Scand J Pain 2016;13:43–58.Search in Google Scholar
[15] Morley S, Davies C, Barton S. Possible selves in chronic pain: self-pain enmeshment, adjustment and acceptance. Pain 2005;115:84–94.Search in Google Scholar
[16] Crombez G, Eccleston C, Van Damme S, Vlaeyen JW, Karoly P. Fear-avoidance model of chronic pain: the next generation. Clin J Pain 2012;28:475–83.Search in Google Scholar
[17] Houben R, Leeuw M, Vlaeyen J, Goubert L, Picavet H. Fear of movement/injury in the general population: factor structure and psychometric properties of an adapted version of the Tampa Scale for Kinesiophobia. J Behav Med 2005;28:415–24.Search in Google Scholar
[18] McSweeney B. Hofstede’s model of national cultural differences and their consequences: a triumph of faith – a failure of analysis. Hum Relat 2002;55:89–117.Search in Google Scholar
[19] Vlaeyen JW, Morley S, Linton S, Boersma K, De Jong J. Pain-related fear: exposure-based treatment for chronic pain. Seattle: IASP Press; 2012.Search in Google Scholar
[20] de Jong JR, Vlaeyen JW, van Eijsden M, Loo C, Onghena P. Reduction of pain-related fear and increased function and participation in work-related upper extremity pain (WRUEP): effects of exposure in vivo. Pain 2012;153:2109–18.Search in Google Scholar
[21] den Hollander M, Goossens M, de Jong J, Ruijgrok J, Oosterhof J, Onghena P, Smeets R, Vlaeyen JW. Expose or protect? A randomized controlled trial of exposure in vivo vs. pain-contingent treatment as usual in patients with complex regional pain syndrome type 1. Pain 2016 [Epub ahead of print].Search in Google Scholar
[22] Fordyce WE. Pain and suffering. A reappraisal. Am Psychol 1988;43:276–83.Search in Google Scholar
© 2016 Scandinavian Association for the Study of Pain
Articles in the same Issue
- Scandinavian Journal of Pain
- Editorial comment
- Increased deep pain sensitivity in persistent musculoskeletal pain but not in other musculoskeletal pain states
- Clinical pain research
- Increased deep pain sensitivity in persistent musculoskeletal pain but not in other musculoskeletal pain states
- Editorial comment
- Patient Reported Outcomes (PROs) are sensitive outcome-variables in patients with chronic pain: Importance of self-efficacy
- Observational study
- Using patient reported outcomes in oncology clinical practice
- Editorial comment
- Cortical reorganization of the healthy hand in upper-limb complex regional pain syndrome(CRPS): Is reorganizations of common beliefs about CRPS necessary?
- Original experimental
- An exploration into the cortical reorganisation of the healthy hand inupper-limb complex regional pain syndrome
- Editorial comment
- Is there hope for the most complicated chronic pain patients facing back surgery?
- Educational case report
- A preoperative interdisciplinary biopsychosocial opioid reduction program in patients on chronic opioid analgesia prior to spine surgery: A preliminary report and case series
- Editorial comment
- Pain management in the Emergency Department – Still a long way to go?
- Clinical pain research
- Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients’ satisfaction of pain management
- Editorial comment
- Pain relief during childbirth: Efficacy and safety of prolonging labour-analgesia with morphine directly into the lumbar cerebro-spinal-fluid (CSF)
- Systematic review
- Prolonging the duration of single-shot intrathecal labour analgesia with morphine: A systematic review
- Editorial comment
- The intricate relationship amongst pain intensity, fear and avoidance
- Systematic review
- A meta-analysis of fear-avoidance and pain intensity: The paradox of chronic pain
- Editorial comment
- Local infiltration analgesia(LIA), risk of local anaesthetic systemic toxicity (LAST) and kidney failure from NSAID in elderly patients
- Topical review
- Local infiltration analgesia in knee and hip arthroplasty efficacy and safety
- Editorial comment
- Analysis of pain-intensity measurements
- Topical review
- How to analyze the Visual Analogue Scale: Myths, truths and clinical relevance
- Editorial comment
- The relationship between chronic pain and cardiovascular disease: Squaring the circle?
- Systematic review
- Assessing the relationship between chronic pain and cardiovasculardisease: A systematic review and meta-analysis
- Editorial comment
- Optimists fare better when chronic pain strikes – Or does pain related disability make us pessimists?
- Observational study
- Constructs of health belief and disabling distal upper limb pain
- Editorial comment
- Attitude and belief of pain-therapists are important when trying to help chronic pain patients: The Norwegian version of the Pain Attitudes and Beliefs Scale (PABS) improved by Rasch analysis
- Observational study
- Rasch analysis resulted in an improved Norwegian version of the Pain Attitudes and Beliefs Scale(PABS)
- Editorial comment
- Anxiety could play a larger role than depression in migraine headache
- Clinical pain research
- The relative importance of anxiety and depression in pain impact in individuals with migraine headaches
- Editorial comment
- Bringing the lab to the people: Experimental pain testing in the general population
- Clinical pain research
- Pressure and cold pain threshold reference values in a large, young adult, pain-free population
- Editorial comment
- Improving pain treatment in children
- Clinical pain research
- A randomized controlled trial of amitriptyline versus gabapentin for complex regional pain syndrome type I and neuropathic pain in children
- Editorial comment
- Gut gateway to generalized pain
- Original experimental
- A low fermentable oligo-di-mono saccharides and polyols(FODMAP) diet reduced pain and improve ddaily life in fibromyalgia patients
- Editorial comment
- Measuring outcomes of pain management
- Clinical pain research
- Osteoarthritis patients with pain improvement are highly likely to also have improved quality of life and functioning. A post hoc analysis of a clinical trial
- Clinical pain research
- Construct validity and reliability of Finnish version of Örebro Musculoskeletal Pain Screening Questionnaire
- Observational study
- Total sleep deprivation and pain perception during cold noxious stimuli in humans
- Corrigendum
- Corrigendum to ‘Reliability of pressure pain threshold testing in healthy pain free young adults’ [Scand. J. Pain 9 (2015) 38–41]
Articles in the same Issue
- Scandinavian Journal of Pain
- Editorial comment
- Increased deep pain sensitivity in persistent musculoskeletal pain but not in other musculoskeletal pain states
- Clinical pain research
- Increased deep pain sensitivity in persistent musculoskeletal pain but not in other musculoskeletal pain states
- Editorial comment
- Patient Reported Outcomes (PROs) are sensitive outcome-variables in patients with chronic pain: Importance of self-efficacy
- Observational study
- Using patient reported outcomes in oncology clinical practice
- Editorial comment
- Cortical reorganization of the healthy hand in upper-limb complex regional pain syndrome(CRPS): Is reorganizations of common beliefs about CRPS necessary?
- Original experimental
- An exploration into the cortical reorganisation of the healthy hand inupper-limb complex regional pain syndrome
- Editorial comment
- Is there hope for the most complicated chronic pain patients facing back surgery?
- Educational case report
- A preoperative interdisciplinary biopsychosocial opioid reduction program in patients on chronic opioid analgesia prior to spine surgery: A preliminary report and case series
- Editorial comment
- Pain management in the Emergency Department – Still a long way to go?
- Clinical pain research
- Mandatory documentation of pain in the emergency department increases analgesic administration but does not improve patients’ satisfaction of pain management
- Editorial comment
- Pain relief during childbirth: Efficacy and safety of prolonging labour-analgesia with morphine directly into the lumbar cerebro-spinal-fluid (CSF)
- Systematic review
- Prolonging the duration of single-shot intrathecal labour analgesia with morphine: A systematic review
- Editorial comment
- The intricate relationship amongst pain intensity, fear and avoidance
- Systematic review
- A meta-analysis of fear-avoidance and pain intensity: The paradox of chronic pain
- Editorial comment
- Local infiltration analgesia(LIA), risk of local anaesthetic systemic toxicity (LAST) and kidney failure from NSAID in elderly patients
- Topical review
- Local infiltration analgesia in knee and hip arthroplasty efficacy and safety
- Editorial comment
- Analysis of pain-intensity measurements
- Topical review
- How to analyze the Visual Analogue Scale: Myths, truths and clinical relevance
- Editorial comment
- The relationship between chronic pain and cardiovascular disease: Squaring the circle?
- Systematic review
- Assessing the relationship between chronic pain and cardiovasculardisease: A systematic review and meta-analysis
- Editorial comment
- Optimists fare better when chronic pain strikes – Or does pain related disability make us pessimists?
- Observational study
- Constructs of health belief and disabling distal upper limb pain
- Editorial comment
- Attitude and belief of pain-therapists are important when trying to help chronic pain patients: The Norwegian version of the Pain Attitudes and Beliefs Scale (PABS) improved by Rasch analysis
- Observational study
- Rasch analysis resulted in an improved Norwegian version of the Pain Attitudes and Beliefs Scale(PABS)
- Editorial comment
- Anxiety could play a larger role than depression in migraine headache
- Clinical pain research
- The relative importance of anxiety and depression in pain impact in individuals with migraine headaches
- Editorial comment
- Bringing the lab to the people: Experimental pain testing in the general population
- Clinical pain research
- Pressure and cold pain threshold reference values in a large, young adult, pain-free population
- Editorial comment
- Improving pain treatment in children
- Clinical pain research
- A randomized controlled trial of amitriptyline versus gabapentin for complex regional pain syndrome type I and neuropathic pain in children
- Editorial comment
- Gut gateway to generalized pain
- Original experimental
- A low fermentable oligo-di-mono saccharides and polyols(FODMAP) diet reduced pain and improve ddaily life in fibromyalgia patients
- Editorial comment
- Measuring outcomes of pain management
- Clinical pain research
- Osteoarthritis patients with pain improvement are highly likely to also have improved quality of life and functioning. A post hoc analysis of a clinical trial
- Clinical pain research
- Construct validity and reliability of Finnish version of Örebro Musculoskeletal Pain Screening Questionnaire
- Observational study
- Total sleep deprivation and pain perception during cold noxious stimuli in humans
- Corrigendum
- Corrigendum to ‘Reliability of pressure pain threshold testing in healthy pain free young adults’ [Scand. J. Pain 9 (2015) 38–41]
