(Image directly copied from Vlaeyen & Linton, 2012)
• Long-term avoidance of pain-related behaviors due to fear of pain may increase sensitization to pain and pain-related stimuli, decrease self-efficacy, increase expectation of pain, and increase pain perception, ultimately perpetuating pain-related disability and functional impairment.
• Increased willingness to experience pain and graded exposure to situations or behaviors perceived to be threatening is effective in reducing pain-related fears and subsequent pain-related avoidance and disability among individuals with chronic pain.
Fear and Avoidance in the Development and Maintenance of Chronic Pain
Traditional biomedical models of pain suggest that an individual’s pain experience should directly match the physical damage incurred and that similar injuries should result in similar pain. However, pain isn’t that simple. Rarely will two individuals with identical physical injuries report the exact same pain. For that matter, two individuals with the same injury will likely demonstrate differences in impairment and suffering. These observed discrepancies between expected and reported pain and disability suggest a more complex relationship; one that has led researchers to examine the role of psychological and behavioral factors in the development and maintenance of chronic pain conditions.
The fear-avoidance model (Vlaeyen & Linton, 2000; 2012) details a potential pathway for the development of pain disability, affective distress, and physical disuse resulting from anxiety- and fear-related avoidance behaviors and provides a platform for understanding the dynamic relationship between psychological factors and chronic pain. The fear-avoidance model suggests that pain-related avoidance behaviors and withdrawal, as well as increased vigilance toward internal bodily sensations and external threats of pain, play an adaptive and functional role in protecting the body. It’s healthy to avoid behaviors that cause pain – at least in the short-term. For example, bending or lifting heavy objects may be avoided in order to limit lower back pain from a previous injury. Although adaptive in promoting recovery in acute phases of pain, prolonged avoidance and hypervigilance behaviors may serve to maintain or even exacerbate pain symptoms in the long term by inadvertently increasing pain disability and affective distress. That is, long-term avoidance of pain-related behaviors is maladaptive and ultimately increases pain and pain-related disability.
Pain-related fear and negative affective states play an integral role in escape and avoidance behaviors, suggesting that the meaning of pain may be just as important as the actual experience of pain. When pain is feared and viewed as dangerous, an individual may act in anticipation of pain, rather than in direct response to pain. Avoiding movements due to pain-related fears may contribute to physical deconditioning, negative affect or affective comorbidities, and preoccupation with physical and somatic symptoms associated with pain. These effects in turn may increase sensitization to pain and pain-related stimuli, decrease self-efficacy, increase expectation of pain, and increase pain perception, ultimately perpetuating pain-related disability and functional impairment.
The Good News
You don’t need to change a patient’s beliefs or fear of pain to reduce their avoidance of pain-related behaviors. Graded exposure to situations or behaviors perceived to be threatening is effective in reducing pain-related fears and subsequent pain-related avoidance and disability among individuals with trauma-related neck pain (de Jong et al., 2008), upper extremity pain (de Jong et al., 2012), complex regional pain syndrome (de Jong et al., 2005) and chronic low back pain (Vlaeyen et al., 2001; 2002). Exposure-based treatments are some of the most effective and widely-used psychological interventions for anxiety and trauma-related disorders and have gained continuing support in the treatment of chronic pain conditions. By providing education about the role of avoidance behaviors in the maintenance and development of pain and systematically increasing engagement in feared or pain-related behaviors, psychological and physical therapists can effectively reduce pain-related fear and anxiety and enhance effective recovery through confrontation and increased self-efficacy.
de Jong, J. R., Vangronsveld, K., Peters, M. L., Goossens, M. E. J. B., Onghena, P., Bulté, I., & Vlaeyen, J. W. S. (2008). Reduction of pain-related fear and disability in post-traumatic neck pain: A replicated single-case experimental study of exposure in vivo. The Journal of Pain, 9, 1123-1134.
de Jong, J. R., Vlaeyen, J. W. S., van Eijsken, M., Loo, C., & Onghena, P. (2012a). Reduction of pain-related fear and increased function and participants in work-related upper extremity pain (WRUEP): Effects of exposure in vivo. Pain, 153, 2109-2118.
de Jong, J. R., Vlaeyen, J. W. S., Onghena, P., Cuypers, C., den Hollander, M., & Ruijgrok, J. (2005). Reduction of pain-related fear in complex regional pain syndrome type I: The application of graded exposure in vivo. Pain, 116, 264-275.
Vlaeyen, J. W. S., de Jong, J. R. Geilen, M., Heuts, P. H., & van Breukelen, G. (2001). Graded exposure in vivo in the treatment of pain-related fear: A replicated single-case experimental design in four patients with chronic low back pain. Behavior Research and Therapy, 39, 151-166.
Vlaeyen, J. W. S., de Jong, J. R. Geilen, M., Heuts, P. H., & van Breukelen, G. (2002). The treatment of fear of movement/(re)injury in chronic low back pain: Further evidence on the effectiveness of exposure in vivo. The Clinical Journal of Pain, 18, 251-261
Vlaeyen, J. W. S., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: A state of the art. Pain, 85, 317-332.
Vlaeyen, J. W. S., & Linton, S. J. (2012). Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain, 153, 1144-1147.