Fear-avoidance Model Of Chronic Pain Research Articles

Non-Pharmacological Interventions for Chronic Pain in Older Adults: A Systematic Review and Meta-Analysis.

Gate control theory and fear-avoidance model of chronic pain posit that biopsychosocial factors can modulate pain. Non-pharmacological interventions are recommended in managing chronic pain, but little information is available regarding their efficacy in older adults. We examined and compared the efficacy of different non-pharmacological intervention approaches for chronic pain management among older adults via meta-analysis and subgroup analysis. Following the PRISMA guidelines (PROSPERO number CRD42020222767), a systematic search was undertaken using MEDLINE, Embase, and PsycINFO up to 21 March 2022. Randomized controlled trials were included, and data were pooled using a random-effects meta-analysis model. Risk of bias was assessed using a quality rating scale for psychological interventions. Twenty-five trials (N = 2394 participants) were identified. Six types of non-pharmacological interventions were compared with control conditions (sham/attention control and treatment as usual). Non-pharmacological interventions were associated with significant reductions in pain intensity, pain interference, depressive symptoms and catastrophizing beliefs and improvement in physical performance (standardized mean differences [SMDs] -0.34 to 0.54). Subgroup analyses based on different non-pharmacological approaches revealed the benefits of psychological approaches combined with physical activity. Non-pharmacological interventions, particularly those adopting psychological approaches and physical activity, have a small but statistically significant effect on chronic pain management in older adults. Reduction in pain interference may be related to reduced catastrophizing beliefs, thus providing support for the fear-avoidance model. Further research with adequate power is needed to establish the efficacy and mechanism of various intervention modalities for older adults.

Predictors of Psychosocial and Functional Outcomes in Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia: Application of the Fear-Avoidance Model

Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD), which affects up to 4.3% of individuals, is a distressing and poorly understood condition characterized by persistent, unwanted, and often painful sensations of genito-pelvic arousal (eg, throbbing) in the absence of sexual desire. PGAD/GPD is associated with significant negative impacts on psychosocial well-being and daily functioning. Recent research has indicated that PGAD/GPD shares many similarities with other forms of chronic genito-pelvic pain. This study applied the fear-avoidance model of chronic pain to PGAD/GPD to identify cognitive and behavioral factors associated with psychosocial and functional outcomes. A total of 263 individuals with PGAD/GPD symptoms completed a cross-sectional online survey of symptom intensity, cognitive and behavioral predictors (symptom catastrophizing, hypervigilance to symptoms, symptom fear and avoidance, self-efficacy), depression symptoms, and role functioning. Symptom catastrophizing, fear of symptoms, avoidance of symptoms, and hypervigilance to PGAD/GPD symptoms were significantly correlated with poorer psychosocial and functional outcomes, whereas higher self-efficacy was significantly associated with lower depression and better role functioning. Two serial parallel mediation models examined the fear-avoidance pathway from PGAD/GPD symptom intensity to depression symptoms and role functioning. In both models, the pathway through symptom catastrophizing, fear of symptoms, and symptom avoidance was significant, but the pathway through symptom catastrophizing, fear of symptoms, and symptom hypervigilance was not. The results of this study provide support for the applicability of the fear-avoidance model to PGAD/GPD. Interventions targeting fear-avoidance factors may help to reduce PGAD/GPD symptom intensity, distress, and increase psychological well-being and daily functioning. PerspectiveThis article provides support for the applicability of the fear-avoidance model of chronic pain to Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD). These results suggest that interventions targeting fear-avoidance cognitions and behaviors (catastrophizing, fear, avoidance, hypervigilance) may help to reduce PGAD/GPD symptom intensity and improve psychological well-being and daily functioning.

Increased positive affect is associated with less generalization of pain-related avoidance

Fear-avoidance models of chronic pain consider excessive spreading (or overgeneralization) of pain-related avoidance toward safe activities to play a crucial role in chronic pain disability. This study (N = 96) investigated whether avoidance generalization is mitigated by positive affect induction. Pain-free, healthy participants performed an arm-reaching task during which certain movements were followed by pain, while another was not. One group then performed an exercise to induce positive affect (positive affect group), while another group performed a neutral exercise (neutral group). A third group also performed the neutral exercise, but did not learn to avoid pain during the arm-reaching task (yoked neutral group). To test generalization, we introduced novel but similar movements that were never followed by pain in all groups. Results showed no differences in generalization between the positive affect and neutral groups; however, across groups, higher increases in positive affect were associated with less generalization of avoidance, and less generalization of pain-expectancy and pain-related fear. Compared to the yoked neutral group, the neutral group showed avoidance generalization, as well as pain-expectancy and pain-related fear generalization. These results point toward the potential of positive affect interventions in attenuating maladaptive spreading of pain-related avoidance behavior to safe activities.

A meta-analysis of the associations of elements of the fear-avoidance model of chronic pain with negative affect, depression, anxiety, pain-related disability and pain intensity.

Background and objectiveBiopsychosocial conceptualizations of clinical pain conditions recognize the multi‐faceted nature of pain experience and its intersection with mental health. A primary cognitive‐behavioural framework is the Fear‐Avoidance Model, which posits that pain catastrophizing and fear of pain (including avoidance, cognitions and physiological reactivity) are key antecedents to, and drivers of, pain intensity and disability, in addition to pain‐related psychological distress. This study aimed to provide a comprehensive analysis of the magnitude of the cross‐sectional association between the primary components of the Fear‐Avoidance Model (pain catastrophizing, fear of pain, pain vigilance) with negative affect, anxiety, depression, pain intensity and disabilities in studies of clinical pain.Databases and data treatmentA search of MEDLINE and PubMed databases resulted in 335 studies that were evaluated in this meta‐analytic review, which represented 65,340 participants.ResultsResults from the random effect models indicated a positive, medium‐ to large‐sized association between fear of pain, pain catastrophizing, and pain vigilance measures and outcomes (pain‐related negative affect, anxiety, depression and pain‐related disability) and medium‐sized associations with pain intensity. Fear of pain measurement type was a significant moderator of effects across all outcomes.ConclusionsThese findings provide empirical support, aligned with the components of the fear‐avoidance (FA) model, for the relevance of both pain catastrophizing and fear of pain to the pain experience and its intersection with mental health. Implications for the conceptualization of the pain catastrophizing and fear of pain construct and its measurement are discussed.SignificanceThis meta‐analysis reveals that, among individuals with various pain conditions, pain catastrophizing, fear of pain, and pain vigilance have medium to large associations with pain‐ related negative affect, anxiety, and depression, pain intensity and disability. Differences in the strength of the associations depend on the type of self‐report tool used to assess fear of pain.

Associations between biased threat interpretations, fear and avoidance of pain and pain-linked disability in adolescent chronic pain patients.

Biased interpretations of ambiguous bodily threat situations characterize youth with chronic pain, and have been associated with functional disability for this population. Despite predictions by the fear-avoidance model of chronic pain, that fear and avoidance of pain explain the association between threat perceptions and disability, this has not yet been explored in youth with chronic pain. This study aimed to address this gap by investigating these proposed relationships, in addition to the association between bodily threat interpretations and daily aspects of disability (as well as social, and emotional impairments). Sixty-eight adolescents aged 11-18years old with a clinical diagnosis of chronic pain completed an extended version of the Adolescent Interpretations of Bodily Threat task to assess interpretations of bodily and social threat situations, alongside measures of disability and fear and avoidance of pain. Using mediation analysis, fear and avoidance of pain statistically accounted for the relationship between negative bodily threat interpretations and functional disability. Significant associations were also demonstrated between negative bodily threat interpretations and adolescent-reported impairments in daily, emotional and social impairments. Data revealed a significant relationship between negative social interpretations and daily functional disability. Findings indicate the clinical relevance of bodily and social threat interpretations, and fear and avoidance of pain, for this population and raise further questions regarding the content-specificity of threat interpretations. Psychological theories of pain-associated impact and disability point to fear and avoidance of pain, as well as information-processing biases. Here, we present novel data showing the clinical relevance of bodily and social threat interpretations in explaining pain-related disability amongst youth with chronic pain, potentially by shaping fear and avoidance of pain. Longitudinal designs will be required to assess these temporally sensitive mediation pathways.

Avoidance behaviour performed in the context of a novel, ambiguous movement increases threat and pain-related fear.

The fear-avoidance model of chronic pain predicts that catastrophic (mis)interpretation of pain elicits pain-related fear that in turn may spur avoidance behaviour leading to chronic pain disability. Here, we investigated whether performing a movement to avoid a painful stimulus in the context of a novel movement increases threat and pain-related fear towards this novel movement and whether avoidance behaviour persisted when given the choice between performing the acquired movement to avoid a painful stimulus or an alternative, novel movement. Applying a robotic arm-reaching task, participants could choose between 2 movements to reach a target location: a short, but painful movement trajectory, or a longer nonpainful movement trajectory. After avoidance acquisition, the option to choose the painful trajectory was removed. The experimental group (N = 50) could choose between the longest trajectory or a novel intermediate trajectory, whereas the control group (N = 50) was allowed to only perform the novel trajectory. In a final test, participants of both groups were allowed to choose any of the 3 trajectories. After acquisition, experimental group participants showed elevated pain expectancy and pain-related fear towards the novel trajectory, compared with the control group. During test, the experimental group participants persisted in performing the longest pain-free (avoidance) trajectory and were less likely to choose the novel trajectory. In addition, these participants maintained higher levels of pain-related fear for the novel trajectory compared with the control group. These findings suggest that avoidance in the context of other neutral activities/movements may lead to the development and maintenance of threat appraisals and irrational fears.

From gut feelings to memories of visceral pain

Abstract The role of pain-related fear learning and memory processes, conceptually embedded within the fear-avoidance model of chronic pain, is increasingly recognized. The unique biological salience of interoceptive, visceral pain with its cognitive, emotional, and motivational facets fosters associative learning. Conditioned fear is in principle adaptive but may turn maladaptive and contribute to hypervigilance and hyperalgesia in chronic pain. This review summarizes current knowledge on the formation, extinction, and return of pain-related memories with a focus on visceral pain. It provides a conceptual background, describes experimental approaches, and summarizes findings on behavioral and neural mechanisms in healthy humans and patients with chronic pain. Future directions underscore the potential of refining knowledge on the role of associative learning in the pathophysiology and treatment of chronic visceral pain in disorders of gut–brain interactions such as irritable bowel syndrome.

The acquisition and generalization of fear of touch.

Objectives Contemporary fear-avoidance models of chronic pain posit that fear of pain, and overgeneralization of fear to non-threatening stimuli is a potential pathway to chronic pain. While increasing experimental evidence supports this hypothesis, a comprehensive investigation requires testing in multiple modalities due to the diversity of symptomatology among individuals with chronic pain. In the present study we used an established tactile fear conditioning paradigm as an experimental model of allodynia and spontaneous pain fluctuations, to investigate whether stimulus generalization occurs resulting in fear of touch spreading to new locations. Methods In our paradigm, innocuous touch is presented either paired (predictable context) or unpaired (unpredictable context) with a painful electrocutaneous stimulus (pain-US). In the predictable context, vibrotactile stimulation to the index or little finger was paired with the pain-US (CS+), whilst stimulation of the other finger was never paired with pain (CS-). In the unpredictable context, vibrotactile stimulation to the index and little fingers of the opposite hand (CS1 and CS2) was unpaired with pain, but pain-USs occurred unpredictable during the intertrial interval. During the subsequent generalization phase, we tested the spreading of conditioned responses (self-reported fear of touch and pain expectancy) to the (middle and ring) fingers between the CS+ and CS-, and between the CS1 and CS2. Results Differential fear acquisition was evident in the predictable context from increased self-reported pain expectancy and self-reported fear for the CS+compared to the CS-. However, expectancy and fear ratings to the novel generalization stimuli (GS+ and GS-) were comparable to the responses elicited by the CS-. Participants reported equal levels of pain expectancy and fear to the CS1 and CS2 in the unpredictable context. However, the acquired fear did not spread in this context either: participants reported less pain expectancy and fear to the GS1 and GS2 than to the CS1 and CS2. As in our previous study, we did not observe differential acquisition in the startle responses. Conclusions Whilst our findings for the acquisition of fear of touch replicate the results from our previous study (Biggs etal., 2017), there was no evidence of fear generalization. We discuss the limitations of the present study, with a primary focus on procedural issues that were further investigated with post-hoc analyses, concluding that the present results do not show support for the hypothesis that stimulus generalization underlies spreading of fear of touch to new locations, and discuss how this may be the consequence of a context change that prevented transfer of acquisition.

Longitudinal Analysis Supports a Fear-Avoidance Model That Incorporates Pain Resilience Alongside Pain Catastrophizing.

The fear-avoidance model of chronic pain holds that individuals who catastrophize in response to injury are at risk for pain-related fear and avoidance behavior, and ultimately prolonged pain and disability. Based on the hypothesis that the predictive power of the fear-avoidance model would be enhanced by consideration of positive psychological constructs, the present study examined inclusion of pain resilience and self-efficacy in the model. Men and women (N = 343) who experienced a recent episode of back pain were recruited in a longitudinal online survey study. Over a 3-month interval, participants repeated the Pain Resilience Scale, Pain Catastrophizing Scale, Tampa Scale of Kinesiophobia, Pain Self-Efficacy Questionnaire, the McGill Pain Questionnaire, and NIH-recommended measures of pain, depressive symptoms, and physical dysfunction. Structural equation modeling assessed the combined contribution of pain resilience and pain catastrophizing to 3-month outcomes through the simultaneous combination of kinesiophobia and self-efficacy. An expanded fear-avoidance model that incorporated pain resilience and self-efficacy provided a good fit to the data, Χ2 (df = 14, N = 343) = 42.09, p = .0001, RMSEA = 0.076 (90% CI: 0.05, 0.10), CFI = 0.97, SRMR = 0.03, with higher levels of pain resilience associated with improved 3-month outcomes on measures of pain intensity, physical dysfunction, and depression symptoms. This study supports the notion that the predictive power of the fear-avoidance model of pain is enhanced when individual differences in both pain-related vulnerability (e.g., catastrophizing) and pain-related protective resources (e.g., resilience) are considered.

(311) Relationships between Objective Physical Performance with Pain Anxiety and Self-Efficacy during Intensive Pediatric Pain Rehabilitation

Intensive interdisciplinary pain rehabilitation programs (IIPRP) are typically recommended for youth with chronic pain conditions who do not respond to outpatient pain clinic treatment. A growing body of literature has shown that IIPRP are associated with improvements in functioning, pain, and distress. However, little is known about treatment mechanisms for IIPRP. A few studies have documented improvements in physical functioning within IIPRP, but how these improvements contribute to other areas of functioning remains unexplored. Existing conceptual models (fear-avoidance model of chronic pain, self-efficacy model) suggest that pain-related anxiety and self-efficacy may be important treatment mechanisms for youth undergoing IIPRP. For this study, we hypothesized that improvements in physical functioning (measured via objective measures of gait speed and core and upper strength) would be associated with changes in self-report measures of pain-related anxiety and self-efficacy. For this preliminary analysis, 10 participants, ages 10-16, completed measures prior to and upon completion of an IIPRP where they received physical and occupational therapy, pain psychology, and medical services for 1-3 weeks. Measures included the Fear of Pain Questionnaire, Self-Efficacy Scale, 100-Foot Walk, and the Sit-Up and Push-Up subtests of the Bruininks-Oseretsky Test of Motor Proficiency, 2nd Edition. Regression analyses produced standardized residuals for change scores. Preliminary results indicate improvements in gait speed and core strength were related to improvements in fear of pain (rs > 0.60, ps

Mindfulness and Chronic Headache/Migraine: Mechanisms Explored Through the Fear-Avoidance Model of Chronic Pain.

To replicate a study by Schutze and colleagues on a headache sample, rather than a heterogenous chronic pain sample, investigating whether level of mindfulness predicts key components in the Fear-Avoidance Model of chronic pain (pain intensity, negative affect, pain catastrophizing, pain-related fear, pain hypervigilance, and functional disability); to investigate the relationships between level of mindfulness and headache/migraine pain intensity, frequency, and duration. Participants were 217 individuals who self-reported chronic headache/migraine (51 male, 166 female), aged between 18 and 65 years. Participants completed an online survey measuring demographics, mindfulness, the key components of the Fear-Avoidance Model, and headache pain intensity, duration, and frequency. Mindfulness had significant negative correlations (P<0.05) with all variables except headache pain intensity and headache frequency. Mindfulness significantly predicted negative affect, pain catastrophizing, fear of pain, pain hypervigilance, and headache duration (P<0.05). Mindfulness remained a significant predictor of negative affect and pain hypervigilance after controlling for other key components and background characteristics (P<0.05). Mindfulness did not moderate the relationship between pain intensity and pain catastrophizing (P=0.204). Findings suggest that mindfulness may be integrated into the Fear-Avoidance Model of chronic pain for individuals with chronic headache/migraine. Directions for future research are discussed.

Broadening the fear-avoidance model of chronic pain?

Broadening the fear-avoidance model of chronic pain?

The relationship between chronic musculoskeletal pain, anxiety and mindfulness: Adjustments to the Fear-Avoidance Model of Chronic Pain

Background and purposeThe Fear-Avoidance Model of Chronic Pain proposed by Vlaeyen and Linton states individuals enter a cycle of chronic pain due to predisposing psychological factors, such as negative affectivity, negative appraisal or anxiety sensitivity. They do not, however, address the closely related concept of anxious rumination. Although Vlaeyen and Linton suggest cognitive-behavioral treatment methods for chronic pain patients who exhibit pain-related fear, they do not consider mindfulness treatments. This cross-sectional study investigated the relationship between chronic musculoskeletal pain (CMP), ruminative anxiety and mindfulness to determine if (1) ruminative anxiety is a risk factor for developing chronic pain and (2) mindfulness is a potential treatment for breaking the cycle of chronic pain. MethodsMiddle-aged adults ages 35–50 years (N=201) with self-reported CMP were recruited online. Participants completed standardized questionnaires assessing elements of chronic pain, anxiety, and mindfulness. ResultsRuminative anxiety was positively correlated with pain catastrophizing, pain-related fear and avoidance, pain interference, and pain severity but negatively correlated with mindfulness. High ruminative anxiety level predicted significantly higher elements of chronic pain and significantly lower level of mindfulness. Mindfulness significantly predicted variance (R2) in chronic pain and anxiety outcomes. Pain severity, ruminative anxiety, pain catastrophizing, pain-related fear and avoidance, and mindfulness significantly predicted 70.0% of the variance in pain interference, with pain severity, ruminative anxiety and mindfulness being unique predictors. ConclusionsThe present study provides insight into the strength and direction of the relationships between ruminative anxiety, mindfulness and chronic pain in a CMP population, demonstrating the unique associations between specific mindfulness factors and chronic pain elements. ImplicationsIt is possible that ruminative anxiety and mindfulness should be added into the Fear-Avoidance Model of Chronic Pain, with ruminative anxiety as a psychological vulnerability and mindfulness as an effective treatment strategy that breaks the cycle of chronic pain. This updated Fear-Avoidance Model should be explored further to determine the specific mechanism of mindfulness on chronic pain and anxiety and which of the five facets of mindfulness are most important to clinical improvements. This could help clinicians develop individualized mindfulness treatment plans for chronic pain patients.

Yoga attitudes in chronic low back pain: Roles of catastrophizing and fear of movement

Chronic low back pain is a significant public health problem and, although underused, yoga may be an effective complementary treatment. The current study examined associations of pain catastrophizing and fear of movement with attitudes toward yoga in adults with chronic low back pain. Participants completed three quantitative questionnaires assessing specific constructs: beliefs about yoga, fear of movement, and pain catastrophizing. A semi-structured in-person interview was then conducted to obtain specific pain-related information. Hierarchical regression and mediational analyses were used to test hypotheses. Consistent with the fear-avoidance model of chronic pain, catastrophizing and fear of movement were negatively associated with yoga attitudes. Specifically, fear of movement was a mediator between catastrophizing and attitudes toward yoga. Individuals with higher levels of catastrophizing and fear of movement may be less likely to consider a pain treatment involving physical movement.

Do patients with chronic pain show autonomic arousal when confronted with feared movements? An experimental investigation of the fear-avoidance model.

The relevance of a phobia-based conceptualization of fear for individuals with chronic pain has been much debated in the literature. This study investigated whether patients with highly fearful chronic low back pain show distinct physiological reaction patterns compared with less fearful patients when anticipating aversive back pain-related movements. We used an idiosyncratic fear induction paradigm and collected 2 different measures of autonomic nervous system activation and muscle tension in the lower back. We identified 2 distinct psychophysiological response patterns. One pattern was characterized by a moderate increase in skin conductance, interbeat interval (IBI) increase, and muscle tension increase in the lower back. This response was interpreted as an attention reaction to a moderately stressful event. The other pattern, found in 58% of the participants, was characterized by a higher skin conductance response, IBI decrease, and muscle tension increase in the lower back. According to Bradley and Lang defense cascade model, this response is typical of a fear reaction. Participants showing the psychophysiological pattern typical of fear also had elevated scores on some self-report measures of components of the fear-avoidance model, relative to participants showing the reaction pattern characteristic of attention. This study is the first to provide psychophysiological evidence for the fear-avoidance model of chronic pain.

The effectiveness of “Mindfulness based Cognitive Therapy” on psycho-social performance of chronic low back pain patients (CLBP)

AbstractBackground & aim:  One third of people suffer from chronic a condition frequently associated with decreased quality of life and high levels of psychological distress. This study was conducted to examine the effectiveness of Meditation for pain management on pscho-social performance of 18-65 years old women with chronic low back pain )CLBP(.Materials and method:  In this Qusi experimental study, 26 volunteer female patients with CLBP referred to physical therapy, Akhavan hospital, attending a clinical assessment for treatment of chronic pain recruited using convenience sampling. Then they were randomly assigned to experimental and control groups (13 persons in each group). Both groups completed Roland and Morris Disability Questionnaire, Self-efficacy Questionnaire )PSEQ( and Depression Stress Scale)Dass-21(. Meditation for pain management intervention was lasted approximately 8 weeks. focus of this program is on awareness enhancement, attention to cognitive and emotional factors and behavioral activation finally. control group did not receive any psychological intervention..Data was analyzed by spss-15.Finding:  The result of covariance analysis indicated that the disability caused by pain significantly reduced )p=0/00( and pain self-efficacy increased in intervention group (p=0/04(. There was no statistically significant difference in depression scores between two groups (p=0/2).Conclusion:  Results from the present investigation demonstrate that “Mindfulness Meditation for pain management” can enhanced the psychosocial function of patients with chronic pain by reducing the anxiety sensitivity and selective attention to pain stimuli.Keywords: Psychotherapy, Cognitive Therapy , Self-Efficacy, Performance. REFERENCES Ahn S S (2007); The effect of Korean version of Based Stress Reduction program on chronic pain of workers  (Dissertation). Daegu, Korea: Youngnam University. Asghari (2012); Methods of pain assessment, Tehran:     Roshd press . (Persian) Asghari A, Mehrabian N, Paknejad M, Saed F (2010); The psychometric properties of Depression, and Stress Scale in chronic pain patients,     Journal of Psychology and Educational Sciences . 40 42-13. (Persian). Asghari A, Najarian B, Mohamadi M, Dehghani M (2002); Pain psychology, Tehran:     Roshd press . 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The fear-avoidance model of chronic pain: assessing the role of neuroticism and negative affect in pain catastrophizing using structural equation modeling.

Previous research on the fear-avoidance model (FAM) of chronic pain suggests that the personality traits of neuroticism and negative affect (NA) influence pain catastrophizing. However, the mechanisms of their influence on pain catastrophizing remain unclear. This study examined four possible models of relationships between neuroticism, NA, and pain catastrophizing within the FAM framework using structural equation modeling. A total of 401 patients with chronic musculoskeletal pain completed measures of neuroticism, NA, three core FAM components (pain catastrophizing, pain-related fear, and pain anxiety), and adjustment outcomes (pain-related disability and depression). Regression analyses refuted the possibility that neuroticism and NA moderated each other's effect on pain catastrophic thoughts (p > 0.05). Results of structural equation modeling (SEM) evidenced superior data-model fit for the collapsed models in which neuroticism and NA were two secondary traits underlying a latent construct, negative emotion (disability: comparative fit index (CFI) = 0.93; depression: CFI = 0.91). The results offer preliminary evidence that patients presenting with more neurotic symptom and heightened NA probably elicit more catastrophic thoughts about pain.

An examination of the structural link between post‐traumatic stress symptoms and chronic pain in the framework of fear‐avoidance models

The tendency to respond with fear and avoidance can be seen as a shared vulnerability contributing to the development of post-traumatic stress disorder (PTSD) and chronic pain. Although several studies have examined which specific symptoms of PTSD (re-experiencing, avoidance, emotional numbing and hyperarousal) are associated with chronic pain, none has considered this association within the framework of fear-avoidance models. Seven hundred fourteen patients with chronic musculoskeletal pain were assessed. Of these, 149 patients were selected for the study based upon the following inclusion criteria: exposure to a traumatic event before the onset of pain (with scores equal to or higher than 8 points on the fear and hopelessness scales of the Stressful Life Event Screening Questionnaire Revised) and scores equal to or higher than 30 on the Davidson Trauma Scale. Structural equation modelling was used to test the association between PTSD symptoms and pain outcomes (pain intensity and disability) using the mediating variables considered in the fear-avoidance models. The results show that emotional numbing and hyperarousal symptoms, but neither re-experiencing nor avoidance, affected pain outcome via anxiety sensitivity (AS), catastrophizing and fear of pain. PTSD symptoms increased the levels of AS, which predisposes to catastrophizing and, in turn, had an effect on the tendency of pain patients to respond with more fear and avoidance. This study provides empirical support for the potential role of PTSD symptoms in fear-avoidance models of chronic pain and suggests that AS is a relevant variable in the relationship between both disorders.

The Fear Avoidance Model of Chronic Pain: Examination for Pediatric Application

The current study examined the Fear Avoidance (FA) model of chronic pain in pediatric chronic pain patients. Multiple structural equation models were tested in the current study with pairwise parameter comparisons made between younger children (8–12 years) and adolescents (13–17 years). Within a sample of 350 children and adolescents, we examined functional disability and depressive symptoms in separate models with the following predictor variables—pain, pain catastrophizing, fear of pain, and avoidance of activities—after controlling for duration of pain. For a subset of patients (n = 151), we also tested a brief prospective outcome model with baseline predictor variables and functional disability at 1-month follow-up. The FA models predicting functional disability concurrently and prospectively were an excellent fit to the data. The theorized FA model for depression was a poor fit. When the model was modified to include direct pathways from the cognitive processes of pain catastrophizing and fear of pain to depressive symptoms, the model fit was significantly improved. In the examination of developmental differences between younger children and adolescent patients, duration of pain contributed to the model for younger children, whereas pain-related fears were more influential for adolescent patients. PerspectiveThe FA model of chronic pain appears to be applicable for pediatric patients with some modification to account for developmental differences across childhood. We discuss the developmental, theoretical, and clinical implications of these results.

Fear-Avoidance Model of Chronic Pain

The fear-avoidance (FA) model of chronic pain describes how individuals experiencing acute pain may become trapped into a vicious circle of chronic disability and suffering. We propose to extend the FA model by adopting a motivational perspective on chronic pain and disability. A narrative review. There is ample evidence to support the validity of the FA model as originally formulated. There are, however, some key challenges that call for a next generation of the FA model. First, the FA model has its roots in psychopathology, and investigators will have to find a way to account for findings that do not easily fit within such framework. Second, the FA model needs to address the dynamics and complexities of disability and functional recovery. Third, the FA model should incorporate the idea that pain-related fear and avoidance occurs in a context of multiple and often competing personal goals. To address these 3 key challenges, we argue that the next generation of the FA model needs to more explicitly adopt a motivational perspective, one that is built around the organizing powers of goals and self-regulatory processes. Using this framework, the FA model is recast as capturing the persistent but futile attempts to solve pain-related problems to protect and restore life goals.