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Broadening the fear-avoidance model of chronic pain?

  • Jantine J.L.M. Boselie EMAIL logo and Johan W.S. Vlaeyen
Published/Copyright: October 1, 2017
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Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 17 Issue 1

1 The “fear-avoidance model of chronic pain”: what and why?

In this issue of the Scandinavian Journal of Pain, Katherine Curtin and Deborah Norris [1] report on an online cross-sectional study in participants with self-reported chronic musculoskeletal pain (CMP). The study aimed to investigate the impact of ruminative anxiety and mindfulness on components of chronic pain (i.e., pain experience, pain catastrophizing, pain-related fear/avoidance) as proposed in the fear-avoidance model [2]. The fear-avoidance model presents a possible pathway by which injured individuals can get caught into a negative downward spiral, the so-called fear-avoidance cycle, which fuels negative pain-related outcomes. In this vicious cycle, a catastrophic interpretation of pain might lead to pain-related fear, which in turn leads to defensive behaviours (i.e., avoidance and/or hypervigilance), resulting in disability and (more) pain. The authors hypothesise that a maladaptive cognition such as anxious rumination will be a risk factor for developing chronic pain. In contrast, a strategy that corrects this maladaptive cognition, such as mindfulness could be considered as a protective factor against maladjustment to pain. In other words, anxious rumination perpetuates the fear-avoidance cycle while mindfulness could prevent and/or break the fear-avoidance cycle.

2 Anxious rumination and mindfulness needed in the “fear-avoidance model”?

Anxious rumination was measured with the Perceived Stress Scale-10. Mindfulness, defined as cognitive behavioural strategy that promotes present-moment awareness in an intentional and non-judgmental manner, was measured with Five Facet Mindfulness Questionnaire-sf. In line with the author’s expectations, results showed that ruminative anxiety was positively correlated with pain severity (i.e., pain experience), pain catastrophizing, pain-related fear/avoidance, and pain interference, but negatively correlated with mindfulness. Pain severity, pain catastrophizing, pain-related fear/avoidance, ruminative anxiety, and mindfulness significantly predicted 70.0% of the variance in pain interference, with pain severity, ruminative anxiety and mindfulness being unique predictors. These results may incite some doubts regarding the completeness of the fear-avoidance model. The authors propose that the fear-avoidance model should therefore be adjusted to include ruminative anxiety as a predisposing psychological vulnerability and mindfulness as an effective strategy that breaks the cycle of chronic pain.

3 “Building what is strong” better than “fixing what is wrong”?

Including both anxious rumination and mindfulness in the fear-avoidance model is in line with the aim of positive psychology to have a more complete and balanced scientific understanding of the human experience, by abandoning the exclusive focus on vulnerability factors and ‘fixing what is wrong’ towards including protective factors and ‘building what is strong’ [3]. Examining both vulnerability and protective factors will help to disentangle what leads to outcomes of recovery, sustainability (perseverance in valued activities despite pain) and growth (benefit finding due to pain) [4]. In fact, the fear-avoidance model already specified besides the negative downward spiral, a positive upward spiral. When pain does not elicit fear, an injured individual will confront movements or activities associated with pain. This confrontation and engagement in daily activities will result in functional recovery. Originally, the model did not specify other factors, besides the absence of fear that may elicit this upward spiral to recovery. However, since its conception the model has evolved and expanded. Positive affect and optimism were for instance added as factors that fuel this upward spiral, as they may promote the pursuit of valued life goals, in contrast to a persistent attempt to control or to avoid pain [5,6]. Positive affect and optimism can also be regarded as protective factors that can reduce the intensity of fear-avoidance cycle components, such as pain catastrophizing [4,7]. In a similar vein, not only individual characteristics may impact that fear-avoidance cycle, also the social context can be important. For example, the threat value of pain can be increased when health care providers unwittingly transfer their own pain-related fears to their patients [8].

4 Including protective and vulnerability factors within the “fear-avoidance model”

Seeing that there are far more factors to consider in the context of fear-avoidance, the proposed adjustment by Curtin and Norris is therefore maybe too restricted. We propose the inclusion of components that are far more broadly formulated, namely protective and vulnerability factors in contrast to mindfulness and ruminative anxiety, respectively. Moderating factors previously identified by the fear-avoidance model (e.g., negative affectivity and anxiety sensitivity) can then fall within the component vulnerability factors, just as ruminative anxiety (as identified in this study) or other overlapping constructs, such as stress. That is, this study measured ruminative anxiety by assessing perceived stress as it is a component of ruminative anxiety. But persistent stress itself can lead to maladaptive neurobiological changes in pain processing pathways, resulting in enhanced pain sensitivity (i.e., stress-induced hyperalgesia), which in turn can exacerbate the pain condition [9]. In other words, experiencing stress can also be identified as a vulnerability factor in this context, just as much as ruminative anxiety can. Having a more broadly stated component, that can include these different but related vulnerability and protective factors, will parsimoniously preserve the fear-avoidance model’s simplicity while increasing its explanatory value.

5 Vulnerability factors instigate a negative vicious spiral; protective factors incite a positive upward spiral

The effort to identify possible vulnerability and protective factors in the context of chronic pain has obvious theoretical gains. But maybe the most important contribution of these types of studies is that it raises awareness among therapist about these factors. The fear-avoidance model can then be used to explain the patient’s pain condition and how their vulnerability factors can instigate a vicious downward spiral that results in maladjustment to pain. While their protective factors may incite a positive upward spiral, that promotes a positive adaptation to pain. Curtin and Norris take an interesting step in identifying the relation between ruminative anxiety, mindfulness and components of chronic pain. However, as the authors themselves point out, more scientific scrutiny is required to identify the underlying mechanisms by which these factors exert their protective effects against chronic pain suffering.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2017.08.006

Maastricht University, Faculty of Psychology and Neuroscience, Clinical Psychological Science, Universiteitssingel 40, Postbus 616, 6200 MD Maastricht, The Netherlands

  1. Conflict of interest: None declared by the authors.

References

[1] Curtin K, Norris D. The relationship between chronic musculoskeletal pain, anxiety and mindfulness: adjustments to the fear-avoidance model of chronic pain. Scand J Pain 2017;17:156–66.Search in Google Scholar

[2] Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeltal pain: astate of the art. Pain 2000;85:317–32.Search in Google Scholar

[3] Garland EL, Fredrickson B, Kring AM, Johnson DP, Meyer PS, Penn DL. Upward spirals of positive emotions counter downward spirals of negativity: insights from the broaden-and-build theory and affective neuroscience on the treatment of emotion dysfunctions and deficits in psychopathology. Clin Psychol Rev 2010;30:849–64.Search in Google Scholar

[4] Sturgeon JA, Zautra AJ. Resilience: a new paradigm for adaptation to chronic pain. Curr Pain Headach Rep 2010;14:105–12.Search in Google Scholar

[5] Vlaeyen JW, Crombez G, Linton SJ. The fear-avoidance model of pain. Pain 2016;157:1588–9.Search in Google Scholar

[6] 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

[7] Finan PH, Garland EL. The role of positive affect in pain and its treatment. ClinJ Pain 2015;31:177–87.Search in Google Scholar

[8] Ostelo RW, Vlaeyen JW. Attitudes and beliefs of health care providers: extending the fear-avoidance model. Pain 2008;135:3–4.Search in Google Scholar

[9] Jennings EM, Okine BN, Roche M, Finn DP. Stress-induced hyperalgesia. Prog Neurobiol 2014;121:1–18.Search in Google Scholar
Published Online: 2017-10-01
Published in Print: 2017-10-01

© 2017 Scandinavian Association for the Study of Pain

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  91. Observational study
  92. The use of rapid onset fentanyl in children and young people for breakthrough cancer pain
  93. Original experimental
  94. Acid-induced experimental muscle pain and hyperalgesia with single and repeated infusion in human forearm
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  124. Unpredictable pain timings lead to greater pain when people are highly intolerant of uncertainty
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  126. Initial validation of the exercise chronic pain acceptance questionnaire
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  128. Exploring patient experiences of a pain management centre: A qualitative study
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  130. Narratives of life with long-term low back pain: A follow up interview study
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  133. Clinical pain research
  134. Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study
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  136. Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study
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  140. Visualization of painful inflammation in patients with pain after traumatic ankle sprain using [11C]-D-deprenyl PET/CT
  141. Original experimental
  142. Developing a model for measuring fear of pain in Norwegian samples: The Fear of Pain Questionnaire Norway
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https://doi.org/10.1016/j.sjpain.2017.09.014

Articles in the same Issue

  1. Observational study
  2. Perceived sleep deficit is a strong predictor of RLS in multisite pain – A population based study in middle aged females
  3. Clinical pain research
  4. Prospective, double blind, randomized, controlled trial comparing vapocoolant spray versus placebo spray in adults undergoing intravenous cannulation
  5. Clinical pain research
  6. The Functional Barometer — An analysis of a self-assessment questionnaire with ICF-coding regarding functional/activity limitations and quality of life due to pain — Differences in age gender and origin of pain
  7. Clinical pain research
  8. Clinical outcome following anterior arthrodesis in patients with presumed sacroiliac joint pain
  9. Observational study
  10. Chronic disruptive pain in emerging adults with and without chronic health conditions and the moderating role of psychiatric disorders: Evidence from a population-based cross-sectional survey in Canada
  11. Educational case report
  12. Management of patients with pain and severe side effects while on intrathecal morphine therapy: A case study
  13. Clinical pain research
  14. Behavioral inhibition, maladaptive pain cognitions, and function in patients with chronic pain
  15. Observational study
  16. Comparison of patients diagnosed with “complex pain” and “somatoform pain”
  17. Original experimental
  18. Patient perspectives on wait times and the impact on their life: A waiting room survey in a chronic pain clinic
  19. Topical review
  20. New evidence for a pain personality? A critical review of the last 120 years of pain and personality
  21. Clinical pain research
  22. A multi-facet pain survey of psychosocial complaints among patients with long-standing non-malignant pain
  23. Clinical pain research
  24. Pain patients’ experiences of validation and invalidation from physicians before and after multimodal pain rehabilitation: Associations with pain, negative affectivity, and treatment outcome
  25. Observational study
  26. Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy
  27. Clinical pain research
  28. COMBAT study – Computer based assessment and treatment – A clinical trial evaluating impact of a computerized clinical decision support tool on pain in cancer patients
  29. Original experimental
  30. Quantitative sensory tests fairly reflect immediate effects of oxycodone in chronic low-back pain
  31. Editorial comment
  32. Spatial summation of pain and its meaning to patients
  33. Original experimental
  34. Effects of validating communication on recall during a pain-task in healthy participants
  35. Original experimental
  36. Comparison of spatial summation properties at different body sites
  37. Editorial comment
  38. Behavioural inhibition in the context of pain: Measurement and conceptual issues
  39. Clinical pain research
  40. A randomized study to evaluate the analgesic efficacy of a single dose of the TRPV1 antagonist mavatrep in patients with osteoarthritis
  41. Editorial comment
  42. Quantitative sensory tests (QST) are promising tests for clinical relevance of anti–nociceptive effects of new analgesic treatments
  43. Educational case report
  44. Pregabalin as adjunct in a multimodal pain therapy after traumatic foot amputation — A case report of a 4-year-old girl
  45. Editorial comment
  46. Severe side effects from intrathecal morphine for chronic pain after repeated failed spinal operations
  47. Editorial comment
  48. Opioids in chronic pain – Primum non nocere
  49. Editorial comment
  50. Finally a promising analgesic signal in a long-awaited new class of drugs: TRPV1 antagonist mavatrep in patients with osteoarthritis (OA)
  51. Observational study
  52. The relationship between chronic musculoskeletal pain, anxiety and mindfulness: Adjustments to the Fear-Avoidance Model of Chronic Pain
  53. Clinical pain research
  54. Opioid tapering in patients with prescription opioid use disorder: A retrospective study
  55. Editorial comment
  56. Sleep, widespread pain and restless legs — What is the connection?
  57. Editorial comment
  58. Broadening the fear-avoidance model of chronic pain?
  59. Observational study
  60. Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic
  61. Editorial comment
  62. The burden of central anticholinergic drugs increases pain and cognitive dysfunction. More knowledge about drug-interactions needed
  63. Editorial comment
  64. A case-history illustrates importance of knowledge of drug-interactions when pain-patients are prescribed non-pain drugs for co-morbidities
  65. Editorial comment
  66. Why can multimodal, multidisciplinary pain clinics not help all chronic pain patients?
  67. Topical review
  68. Individual variability in clinical effect and tolerability of opioid analgesics – Importance of drug interactions and pharmacogenetics
  69. Editorial comment
  70. A new treatable chronic pain diagnosis? Flank pain caused by entrapment of posterior cutaneous branch of intercostal nerves, lateral ACNES coined LACNES
  71. Clinical pain research
  72. PhKv a toxin isolated from the spider venom induces antinociception by inhibition of cholinesterase activating cholinergic system
  73. Clinical pain research
  74. Lateral Cutaneous Nerve Entrapment Syndrome (LACNES): A previously unrecognized cause of intractable flank pain
  75. Editorial comment
  76. Towards a structured examination of contextual flexibility in persistent pain
  77. Clinical pain research
  78. Context sensitive regulation of pain and emotion: Development and initial validation of a scale for context insensitive avoidance
  79. Editorial comment
  80. Is the search for a “pain personality” of added value to the Fear-Avoidance-Model (FAM) of chronic pain?
  81. Editorial comment
  82. Importance for patients of feeling accepted and understood by physicians before and after multimodal pain rehabilitation
  83. Editorial comment
  84. A glimpse into a neglected population – Emerging adults
  85. Observational study
  86. Assessment and treatment at a pain clinic: A one-year follow-up of patients with chronic pain
  87. Clinical pain research
  88. Randomized, double-blind, placebo-controlled, dose-escalation study: Investigation of the safety, pharmacokinetics, and antihyperalgesic activity of L-4-chlorokynurenine in healthy volunteers
  89. Clinical pain research
  90. Prevalence and characteristics of chronic pain: Experience of Niger
  91. Observational study
  92. The use of rapid onset fentanyl in children and young people for breakthrough cancer pain
  93. Original experimental
  94. Acid-induced experimental muscle pain and hyperalgesia with single and repeated infusion in human forearm
  95. Original experimental
  96. Swearing as a response to pain: A cross-cultural comparison of British and Japanese participants
  97. Clinical pain research
  98. The cognitive impact of chronic low back pain: Positive effect of multidisciplinary pain therapy
  99. Clinical pain research
  100. Central sensitization associated with low fetal hemoglobin levels in adults with sickle cell anemia
  101. Topical review
  102. Targeting cytokines for treatment of neuropathic pain
  103. Original experimental
  104. What constitutes back pain flare? A cross sectional survey of individuals with low back pain
  105. Original experimental
  106. Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain
  107. Clinical pain research
  108. Chronic low back pain and the transdiagnostic process: How do cognitive and emotional dysregulations contribute to the intensity of risk factors and pain?
  109. Original experimental
  110. The impact of the Standard American Diet in rats: Effects on behavior, physiology and recovery from inflammatory injury
  111. Educational case report
  112. Erector spinae plane (ESP) block in the management of post thoracotomy pain syndrome: A case series
  113. Original experimental
  114. Hyperbaric oxygenation alleviates chronic constriction injury (CCI)-induced neuropathic pain and inhibits GABAergic neuron apoptosis in the spinal cord
  115. Observational study
  116. Predictors of chronic neuropathic pain after scoliosis surgery in children
  117. Clinical pain research
  118. Hospitalization due to acute exacerbation of chronic pain: An intervention study in a university hospital
  119. Clinical pain research
  120. A novel miniature, wireless neurostimulator in the management of chronic craniofacial pain: Preliminary results from a prospective pilot study
  121. Clinical pain research
  122. Implicit evaluations and physiological threat responses in people with persistent low back pain and fear of bending
  123. Original experimental
  124. Unpredictable pain timings lead to greater pain when people are highly intolerant of uncertainty
  125. Original experimental
  126. Initial validation of the exercise chronic pain acceptance questionnaire
  127. Clinical pain research
  128. Exploring patient experiences of a pain management centre: A qualitative study
  129. Clinical pain research
  130. Narratives of life with long-term low back pain: A follow up interview study
  131. Observational study
  132. Pain catastrophizing, perceived injustice, and pain intensity impair life satisfaction through differential patterns of physical and psychological disruption
  133. Clinical pain research
  134. Chronic pain disrupts ability to work by interfering with social function: A cross-sectional study
  135. Original experimental
  136. Evaluation of external vibratory stimulation as a treatment for chronic scrotal pain in adult men: A single center open label pilot study
  137. Observational study
  138. Impact of analgesics on executive function and memory in the Alzheimer’s Disease Neuroimaging Initiative Database
  139. Clinical pain research
  140. Visualization of painful inflammation in patients with pain after traumatic ankle sprain using [11C]-D-deprenyl PET/CT
  141. Original experimental
  142. Developing a model for measuring fear of pain in Norwegian samples: The Fear of Pain Questionnaire Norway
  143. Topical review
  144. Psychoneuroimmunological approach to gastrointestinal related pain
  145. Letter to the Editor
  146. Do we need an updated definition of pain?
  147. Narrative review
  148. Is acetaminophen safe in pregnancy?
  149. Book Review
  150. Physical Diagnosis of Pain
  151. Book Review
  152. Advances in Anesthesia
  153. Book Review
  154. Atlas of Pain Management Injection Techniques
  155. Book Review
  156. Sedation: A Guide to Patient Management
  157. Book Review
  158. Basics of Anesthesia
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