Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2016 Oct 1.
Published in final edited form as: Curr Opin Psychol. 2015 Oct 1;5:24–30. doi: 10.1016/j.copsyc.2015.03.014

Pain-Related Fear, Disability, and the Fear-Avoidance Model of Chronic Pain

Emily L Zale 1, Joseph W Ditre 1
PMCID: PMC4383173  NIHMSID: NIHMS674367  PMID: 25844393

Abstract

Chronic pain is a significant public health concern that imposes substantial burdens on individuals and healthcare systems, and factors that contribute to the development and maintenance of pain-related disability are of increasing empirical and clinical interest. Consistent with the fear-avoidance model of chronic pain, greater pain-related fear has consistently been associated with more severe disability and may predict the progression of disability over time. Recent evidence indicates that treatments designed to reduce pain-related fear are efficacious for improving disability outcomes, and several clinical trials are currently underway to test tailored intervention content and methods of dissemination. Future research in this area is needed to identify factors (e.g., substance use, comorbid psychopathology) that may influence interrelations between pain-related fear, response to treatment, and disability.

Introduction

Chronic pain is a significant public health problem that imposes substantial burdens on both individuals and healthcare systems. Recent estimates indicate that chronic pain affects approximately 26–43% of all American adults, and is responsible for greater than $600M in annual healthcare costs and lost productivity [1,2]. Given the substantial and wide-ranging impact of chronic pain, researchers have increasingly focused on the identification of factors that may contribute to the incidence and exacerbation of chronic pain and pain-related disability. The fear-avoidance model of chronic pain posits that pain-related fear plays a central role these processes [3], and the study of potentially bidirectional associations between pain-related fear and disability is an emerging area of clinical and empirical interest across the medical and behavioral sciences. The goals of the current review were to examine and synthesize recent advances in the study of pain-related fear (with a focus on work that has been published since 2012), and to identify factors that may inform future research and the development of novel interventions. We begin with a brief introduction to biopsychosocial perspectives on chronic pain and disability. We then describe the fear-avoidance model of chronic pain, review contemporary research on the topic of pain-related fear and disability, and conclude by identifying psychosocial factors (e.g., comorbid psychopathology) that may influence these associations.

Biopsychosocial Model of Chronic Pain and Pain-Related Disability

According to the biopsychosocial perspective, chronic pain is the result of a complex interplay between biological, psychological, and social factors [4]. The biopsychosocial model provides an optimal framework for conceptualizing pain-related disability because it integrates both medical and psychosocial models [5]. Whereas the medical model views disability as a direct result of disease processes that require treatment or intervention, the psychosocial model posits that environmental (e.g., social, political, physical environment) and individual (e.g., cognitive and affective processes) factors influence the experience of disability. Taken together, a biopsychosocial perspective on disability considers changes to body structure and function (e.g., injury, disease), personal factors (e.g., age, gender), activity limitations (e.g., difficulty executing physical tasks), and participation restrictions (e.g., problems maintaining participation in daily activities) [5].

Pain-related disability encompasses a variety of domains including physical, occupational, recreational, and social functioning. Self-report measures of pain-related disability typically assess pain-related interference with self-care behaviors and family/home responsibilities, physical activity and movement, sleep, sexual activity, recreation, occupation, and social activities [6]. Although not included in all measures, pain intensity and mood ratings may also be considered when assessing pain-related disability. For example, recent approaches to conceptualizing chronic pain severity have taken into account the magnitude and frequency of both pain intensity and pain-related interference [7]. Thus, application of the biopsychosocial model necessitates consideration of a wide range of factors that may contribute to the development and maintenance of chronic pain and disability.

Fear-Avoidance Model and Pain-Related Fear

The fear-avoidance model of chronic pain was originally developed to explain the transition from acute to chronic low back pain [3], and has become a “leading paradigm for understanding disability associated with musculoskeletal conditions” [8]. Research in the area of pain-related fear and disability has increased substantially since the introduction of the fear avoidance-model, with approximately half of the articles retrieved through PubMed (N = 557/1038) and PsycINFO (N =163/346) published in the past 4 years (see Figure 1). Although there is some disagreement among researchers regarding both the sequential relationships between psychosocial risk factors in the fear avoidance model (e.g., whether changes in catastrophizing precede changes in pain-related fear) and future research directions (e.g., relevance of studying cyclical relationships between the model components) in this area [e.g., 8], we are of the opinion that the fear-avoidance model of chronic pain provides a useful framework for the study and treatment of pain-related disability. Below, we review the basic tenants of the fear-avoidance model and discuss recent updates to the model.

Figure 1.

Figure 1

Open in a new tab

Number of citations returned with the search terms (fear of pain OR pain-related fear OR fear-avoidance OR pain-related anxiety) AND disability in PubMed and PsycINFO databases from the introduction of the fear-avoidance model in 2000 to present.

The fear-avoidance model posits that pain-related fear activates escape mechanisms that lead to the avoidance of movement and activity. Although such behavior may be adaptive in the context of acute pain (e.g., by allowing an injury to heal), long-term avoidance of physical activity may impair functioning (e.g., reduced participation in occupational and recreational activities), increase negative mood (e.g., depression), and contribute to greater levels of disability (via disuse syndrome and physical deconditioning). Indeed, greater pain-related fear has been associated with lower levels of physical activity among persons with low-back pain [9], and recent longitudinal evidence indicates that persons with low-back pain who remain sedentary experience greater levels of disability over time [10]. The model further posits that pain-related fear can be negatively reinforced by avoidance behaviors, such that whereas avoidance of fearful stimuli may reduce fear in the short-term, it may also increase or strengthen the fear response over the long-term. In sum, the fear-avoidance model predicts that mutual reinforcement of pain-related fear and avoidance behaviors may contribute to the maintenance and progression of disability.

The related construct of pain-related fear has been conceptualized as representing fear of experiencing pain sensations, fear of activities that may elicit pain, fear of movement or (re)injury, and pain-related anxiety (i.e., anxious or fearful responses to pain). Similar to perceived disability, pain-related fear can be reliably assessed using self-report measures that query fear of experiencing pain, beliefs that pain may be indicative of serious injury or worsened by movement, and specific avoidance behaviors [6]. Pain-related fear and fear-avoidance beliefs have been observed among persons in the general population, and a recent experimental study demonstrated that healthy individuals with no history of chronic pain can evince both increased pain-related fear and delayed recovery (i.e., greater pain intensity and self-reported disability) in response to acute injury [11,12]. These data support the notion that pain-related fear may play an important role in the transition from acute injury to chronic pain and disability.

The fear-avoidance model of chronic pain is an evolving heuristic that has undergone multiple revisions since its introduction over a decade ago. An advantage to this approach is that the fear-avoidance model continues to be informed by ongoing research in this emerging domain. For example, although pain-intensity was not included as a component of the original fear-avoidance model, updated conceptualizations have incorporated evidence that greater pain may motivate avoidance behaviors, and that pain intensity may predict long-term disability outcomes [13]. Additional recent expansions address motivational factors (e.g., conflict between pain-related and non-pain goals), and the acquisition of fear-avoidance beliefs via classical conditioning [14,15]. Researchers have noted that important next steps for the fear avoidance model include consideration of a multidimensional, biopsychosocial definition of pain-related disability, use of a motivational perspective to understand how fear-avoidance behaviors occur in the context of competing demands, and consideration of additional mechanistic factors [8,15].

Associations between Pain-Related Fear and Disability

A growing body of evidence indicates a robust and positive association between pain-related fear and disability among individuals at various stages in the transition from acute to chronic pain. First, a recent review of prospective relations between fear-avoidance and disability (number of studies [k] = 21) concluded that high fear-avoidance beliefs were predictive of work-related disability among patients with sub-acute low-back pain (i.e., pain > 2 weeks and < 3 months) [16]. A similar pattern of findings were observed in a review of randomized controlled trials (RCTs) of non-operative pain treatment (k = 17), such that, among persons with chronic pain for less than 6 months, greater fear-avoidance beliefs at baseline were associated with greater levels of self-reported disability and reduced likelihood of returning to work at 1-month, 6-month, and 1-year follow-ups [17]. Third, the authors of a review of RCTs of surgical intervention for lumbar disc herniation (k = 4) concluded that high fear-avoidance beliefs at baseline tended to be associated with poor surgical outcomes (i.e., pain, disability, return to work) [18]. Notably, of the two systematic reviews that examined associations between pain-related fear and disability as a function of pain duration [16,17], both observed greater consistency in prospective associations between pain-related fear and disability among persons with pain of shorter duration (i.e., < 3 months and < 6 months, respectively). Taken together, these findings suggest that pain-related fear may predict disability even when assessed during the early course of transition from sub-acute to chronic pain. However, given that previous research has tended to rely on categorical classifications of pain onset/duration [16,17], future research would benefit from employing more continuous measures so as to aid in the determination of when the assessment of pain-related fear may yield the greatest predictive utility.

Covariation between pain-related fear and disability has also consistently been observed among persons with chronic pain. A recent meta-analysis of cross-sectional studies (k = 46) demonstrated that associations between pain-related fear and disability were moderate-to-large in magnitude [6]. Moreover, moderation analyses suggested that the positive relation between pain-related fear and disability was stable across demographic (i.e., age and gender) and pain characteristics (i.e., pain intensity, duration, location, treatment-seeking). Although two systematic reviews observed variability in associations between pain-related fear and disability outcomes among persons with chronic pain of longer duration [16,17], meta-analytic estimates derived from cross-sectional studies indicate a robust association between pain-related fear and disability when measured concurrently [6].

Recent longitudinal evidence further indicates that both pre-and post-operative fear of movement may be associated with long-term disability outcomes among lumbar surgery patients [19,20], and that fear-avoidance beliefs among patients with sciatica may be associated with greater latency and reduced likelihood of returning to work [21]. Recent cross-sectional research has also demonstrated positive covariation between pain-related fear and disability among persons with knee osteoarthritis [22], shoulder pain [23], and chronic spinal pain [24]. In addition to self-reported disability, there is also new evidence that fear of movement may be associated with decreased range of motion among patients with chronic neck pain [25], which may, in turn, be associated with greater disability [26].

Pain-Related Fear as a Target for Pain Treatment

The fear-avoidance model of chronic pain predicts that reductions in pain-related fear will enhance disability outcomes. Accordingly, researchers have begun to adapt cognitive-behavioral treatments (CBT) for fear and anxiety in the treatment of pain-related fear. Exposure-based procedures are considered the gold standard treatment for specific phobias (i.e., fear cued by the presence or anticipation of an object or situation), and typically include provision of adaptive coping strategies and exposure to feared situations or objects [27]. According to a recent review, graded exposure treatments that involved (1) development of an individualized hierarchy of feared and avoided activities, and (2) graded confrontation of activities across the hierarchy (beginning with least feared) were efficacious at decreasing levels of pain-related fear and improving functioning among persons with chronic low-back pain [28].

The results of several recent studies further indicate that pain-related fear may be reduced with exposure to movement through a variety of formats, including home-based, telephone guided, and physical therapy/rehabilitation programs. For example, an RCT of outpatients with severe disability due to neck injury revealed decreased fear-avoidance following exercise and strength training [29]. Similar results were observed in an RCT of home-based yoga for low-back pain [30]. There is also evidence that Progressive Goal Attainment (i.e., treatment that facilitates progressive resumption of activities) may reduce fear of movement and (re)injury, and facilitate return to work [31]. Finally, a recent RCT demonstrated that CBT (e.g., activity training and graded exposure in vivo) for persons with low-back pain, who had not yet utilized long-term work-related disability, was efficacious at reducing perceived disability and fear-avoidance beliefs, both immediately after treatment and at 9-month follow-up [32].

Several recent studies have also observed that changes in pain-related fear may mediate the effects of pain treatment on disability outcomes. For example, a systematic review of RCTs for low back pain concluded that decreased fear-avoidance beliefs during treatment were associated with improved disability outcomes, and that treatments that specifically addressed fear-avoidance beliefs were more effective than biomedical treatment alone [17]. Additional recent evidence derived from studies of treatment for anterior knee pain [33] and whiplash [34] suggests that reductions in pain-related fear during treatment may be predictive of reduced disability. Interestingly, one recent study, which utilized a daily diary method to examine changes in pain-related fear during graded exposure treatment, observed a 50% decrease in post-treatment fear of pain and movement, as well as reduced long-term self-reported disability [35]. Additional RCTs are currently underway to test the efficacy of varying durations of graded exposure [36], treatments designed to facilitate progressive goal achievement of goals [37], and post-operative CBT for reducing pain-related fear and disability [38].

Psychosocial Factors Relevant to Pain-Related Fear and Disability

Previous reviews have focused on the role of anxiety sensitivity [39] and self-efficacy [40] as psychosocial constructs that may influence associations between pain-related fear and disability. However, recent research also indicates that co-occurring substance use (e.g., tobacco, cannabis, alcohol) and comorbid psychopathology (e.g., depressive and anxiety disorders) may play a prominent role in complex associations between pain, pain-related fear and disability.

With regard to substance use, pain-related anxiety has been associated with expectancies for negative affect reduction via tobacco smoking among persons in pain [41], and chronic pain patients with greater levels of pain-related anxiety have been shown to be more likely to endorse smoking tobacco to cope with pain [42]. There is also some evidence of covariation between pain-related anxiety and severity of tobacco dependence among persons with and without chronic pain [43,44], there is converging evidence that tobacco smoking may serve an escape/avoidance function in response to pain [45], and smokers have been shown to report greater levels of pain-related disability than nonsmokers [42,46]. Taken together, these data suggest that pain-related anxiety may motivate smoking, and that ongoing tobacco use may be associated with poorer disability outcomes. Similar associations have been observed between pain-related fear and motives for cannabis use [47], researchers have noted that persons with chronic pain may use alcohol for pain-coping [48,49], and the authors of a recent integrative review identified fear-avoidance pathways as a potential mechanism in bidirectional associations between pain and alcohol consumption [48]. We did not, however, identify any studies that explicitly tested interrelations between pain-related fear, disability, and co-occurring substance use. Thus, additional research is needed to examine how substance use may influence the trajectory of pain-related disability within the context of the fear-avoidance model. Future studies should also test whether co-occurring substance use may impair the efficacy of treatments designed to reduce pain-related fear and avoidance behaviors.

With regard to comorbid psychopathology, symptoms of anxiety and depression are both highly prevalent among persons with chronic pain [50,51], and comorbid psychiatric disorders tend to be associated with greater pain-related disability [52]. The fear-avoidance model acknowledges that escape/avoidance behaviors (e.g., withdrawal from daily activities) may contribute to the manifestation of depression. However, it is also possible that symptoms of depression may stimulate fear-avoidance pathways. For example, recent data indicate that pain and depression may interact to promote a negative bias toward health in formation [53], and that negative affect may enhance catastrophic thinking and fear-avoidance beliefs [24,54]. There is also some evidence that anxiety disorders tend to precede the onset of chronic pain [55], and that persons with remitted anxiety or depression continue to demonstrate greater pain intensity and disability than persons with no history of anxiety or depression [56]. Taken together, these findings suggest that both current and historical psychiatric comorbidity should be considered when assessing pain-related fear and disability. Additional research is needed to identify how comorbid psychopathology may influence both the development and maintenance of pain-related disability, as well as response to novel interventions.

Conclusions

Interrelations between pain-related fear and disability are of increasing empirical and clinical interest. Numerous cross-sectional studies have consistently demonstrated positive associations between pain-related fear and disability, and recent meta-analytic estimates indicate that these relations tend to be robust and stable across sociodemographic and pain characteristics. The results of several recent systematic reviews further suggest that pain-related fear may predict the onset of disability, especially when assessed during the transition from acute injury to chronic pain. Consistent with the fear-avoidance model of chronic pain, changes in pain-related fear have been shown to mediate treatment effects on disability, and numerous RCTs are underway to develop efficacious treatments for pain-related fear and disability. The fear-avoidance model of chronic pain represents and evolving conceptualization of pain-related disability, and has undergone several revisions since its introduction more than a decade ago. The current review identified additional biopsychosocial factors (i.e., comorbid substance use a psychopathology) that may influence interrelations between pain-related fear and disability. Future research in this area should examine how these factors may influence the trajectory of pain-related disability or response to interventions that target pain-related fear.

  • Pain-related fear has consistently been associated with more severe disability

  • Treatments designed to reduce pain-related fear may improve disability outcomes

  • The fear-avoidance model has undergone revisions to incorporate new findings

  • Comorbid substance use and psychopathology are important factors for future study

Acknowledgments

This project was supported by Grant No. R21DA034285 and R21DA038204 awarded to Joseph W. Ditre by the National Institute on Drug Abuse.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

  • 1.IOM. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. The National Academies Press; 2011. [PubMed] [Google Scholar]
  • 2.Landmark T, Romundstad P, Dale O, Borchgrevink PC, Kaasa S. Estimating the prevalence of chronic pain: validation of recall against longitudinal reporting (the HUNT pain study) Pain. 2012;153:1368–1373. doi: 10.1016/j.pain.2012.02.004. [DOI] [PubMed] [Google Scholar]
  • 3.Vlaeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317–332. doi: 10.1016/S0304-3959(99)00242-0. [DOI] [PubMed] [Google Scholar]
  • 4.Gatchel R, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133:581–624. doi: 10.1037/0033-2909.133.4.581. [DOI] [PubMed] [Google Scholar]
  • 5.World Health Organization. [Accessed 10/23/14];Towards a common language for functioning, disability, and health. Available from: http://www.who.int/classifications/icf/icfbeginnersguide.pdf?ua=1.
  • 6**.Zale EL, Lange KL, Fields SA, Ditre JW. The Relation Between Pain-Related Fear and Disability: A Meta-Analysis. J Pain. 2013;14:1019–1030. doi: 10.1016/j.jpain.2013.05.005. Synthesized cross-sectional associations between pain-related fear and disability among persons with acute and chronic pain. Effect size estimates indicated that the relation between pain-related fear and disability can be classified as moderate-to-large in magnitude. Results further indicated that the relation is robust across sociodemographic (e.g., age, gender) and pain characteristics (e.g., duration, location, treatment-seeking) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Von Korff M. Assessment of chronic pain in epidemiological and health services research. In: Turk DC, Melzack R, editors. Handbook of Pain Assessment. 3. The Guilford Press; 2011. pp. 455–473. [Google Scholar]
  • 8.Wideman TH, Asmundson GG, Smeets RJ, Zautra AJ, Simmonds MJ, Sullivan MJ, Haythornthwaite JA, Edwards RR. Rethinking the fear avoidance model: toward a multidimensional framework of pain-related disability. Pain. 2013;154:2262–2265. doi: 10.1016/j.pain.2013.06.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Fujii T, Matsudaira K, Oka H. Factors associated with fear-avoidance beliefs about low back pain. J Orthop Sci. 2013;18:909–915. doi: 10.1007/s00776-013-0448-4. [DOI] [PubMed] [Google Scholar]
  • 10.Pinto RZ, Ferreira PH, Kongsted A, Ferreira ML, Maher CG, Kent P. Self-reported moderate-to-vigorous leisure time physical activity predicts less pain and disability over 12 months in chronic and persistent low back pain. Eur J Pain. 2014;18:1190–1198. doi: 10.1002/j.1532-2149.2014.00468.x. [DOI] [PubMed] [Google Scholar]
  • 11.Trost Z, France CR, Thomas JS. Pain-related fear and avoidance of physical exertion following delayed-onset muscle soreness. PAIN. 2011;152:1540–1547. doi: 10.1016/j.pain.2011.02.038. [DOI] [PubMed] [Google Scholar]
  • 12.Parr JJ, Borsa PA, Fillingim RB, Tillman MD, Manini TM, Gregory CM, George SZ. Pain-related fear and catastrophizing predict pain intensity and disability independently using an induced muscle injury model. J Pain. 2012;13:370–378. doi: 10.1016/j.jpain.2011.12.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med. 2007;30:77–94. doi: 10.1007/s10865-006-9085-0. [DOI] [PubMed] [Google Scholar]
  • 14**.Vlaeyen JW, Linton SJ. Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain. 2012;153:1144–1147. doi: 10.1016/j.pain.2011.12.009. Incorporates recent empirical evidence to provide an updated fear-avoidance model of chronic pain. Updates to the model include hypothesized mechanisms responsible for the acquisition of pain-related fear, and consideration of pain-related fear and avoidance behaviors in the context of both pain and non-pain goals. [DOI] [PubMed] [Google Scholar]
  • 15.Crombez G, Eccleston C, Van Damme S, Vlaeyen JW, Karoly P. Fear-avoidance model of chronic pain: the next generation. Clin J Pain. 2012;28:475–483. doi: 10.1097/AJP.0b013e3182385392. [DOI] [PubMed] [Google Scholar]
  • 16**.Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. The Spine Journal. 2014;14:816–836. doi: 10.1016/j.spinee.2013.09.036. Systematic review of longitudinal associations between pain-related fear and disability among patients with non-specific low back pain. Results indicated that greater pain-related fear was associated with increased pain-related disability, particularly among persons with pain lasting < 3 months. These findings indicate that pain-related fear is prognostic for the development of disability, and suggest that early pain interventions should address fear-avoidance beliefs. [DOI] [PubMed] [Google Scholar]
  • 17.Wertli MM, Rasmussen-Barr E, Held U, Weiser S, Bachmann LM, Brunner F. Fear-avoidance beliefs—a moderator of treatment efficacy in patients with low back pain: a systematic review. The Spine Journal. 2014;14:2658–2678. doi: 10.1016/j.spinee.2014.02.033. [DOI] [PubMed] [Google Scholar]
  • 18.Alodaibi FA, Minick KI, Fritz JM. Do preoperative fear avoidance model factors predict outcomes after lumbar disc herniation surgery? A systematic review. Chiropr Man Therap. 2013;21:40. doi: 10.1186/2045-709X-21-40. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Archer KR, Seebach CL, Mathis SL, Riley 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;14:759–767. doi: 10.1016/j.spinee.2013.06.087. [DOI] [PubMed] [Google Scholar]
  • 20.Havakeshian S, Mannion AF. Negative beliefs and psychological disturbance in spine surgery patients: a cause or consequence of a poor treatment outcome? Eur Spine J. 2013;22:2827–35. doi: 10.1007/s00586-013-2822-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Grovle L, Haugen AJ, Keller A, Ntvig B, Brox JI, Grotle M. Prognostic factors for return to work in patients with sciatica. Spine J. 2013;13:1849–1857. doi: 10.1016/j.spinee.2013.07.433. [DOI] [PubMed] [Google Scholar]
  • 22.Sinikallio SH, Helminen EE, Valjakka AL, Vaisanen-Rouvali RH, Arokoski JP. Multiple psychological factors are associated with poorer functioning in a sample of community-dwelling knee osteoarthritis patients. J Clin Rheumatol. 2014;20:261–267. doi: 10.1097/RHU.0000000000000123. [DOI] [PubMed] [Google Scholar]
  • 23.Kromer TO, Sieben JM, de Bie RA, Bastiaenen CH. Influence of fear-avoidance beliefs on disability in patients with subacromial shoulder pain in primary care: a secondary analysis. Phys Ther. 2014;94:1775–1784. doi: 10.2522/ptj.20130587. [DOI] [PubMed] [Google Scholar]
  • 24.Ramirez-Maestre C, Esteve R, Lopez-Martinez A. Fear-avoidance, pain acceptance and adjustment to chronic pain: a cross-sectional study on a sample of 686 patients with chronic spinal pain. Ann Behav Med. 2014;48:402–410. doi: 10.1007/s12160-014-9619-6. [DOI] [PubMed] [Google Scholar]
  • 25.Sarig Bahat H, Weiss PL, Sprecher E, Krasovsky A, Laufer Y. Do neck kinematics correlate with pain intensity, neck disability or with fear of motion? Man Ther. 2014;19:252–258. doi: 10.1016/j.math.2013.10.006. [DOI] [PubMed] [Google Scholar]
  • 26.Saavedra-Hernandez M, Castro-Sanchez AM, Cuesta-Vargas AI, Cleland JA, Fernandez-de-las-Penas C, Arroyo-Morales M. The contribution of previous episodes of pain, pain intensity, physical impairment, and pain-related fear to disability in patients with chronic mechanical neck pain. Am J Phys Med Rehabil. 2012;91:1070–1076. doi: 10.1097/PHM.0b013e31827449a5. [DOI] [PubMed] [Google Scholar]
  • 27.Barlow DH, Allan LG, Basden SL. Psycholoigcal treatments for panic disorders, phobias, and generalized anxiety disorder. In: Nathan PE, Gorman JM, editors. A Guide to Treatments that Work. 3. Oxford University Press; 2007. pp. 351–394. [Google Scholar]
  • 28.Trost Z, Parsons TD. Beyond Distraction: Virtual Reality Graded Exposure Therapy as Treatment for Pain-Related Fear and Disability in Chronic Pain. J Appl Biobehav Res. 2014;19:106–126. [Google Scholar]
  • 29.Rolving N, Christiansen DH, Andersen LL, Skotte J, Ylinen J, Jensen OK, Nielsen CV, Jensen C. Effect of strength training in addition to general exercise in the rehabilitation of patients with non-specific neck pain. A randomized clinical trial. Eur J Phys Rehabil Med. 2014;50:617–626. [PubMed] [Google Scholar]
  • 30.Kim SS, Min WK, Kim JH, Lee BH. The Effects of VR-based Wii Fit Yoga on Physical Function in Middle-aged Female LBP Patients. J Phys Ther Sci. 2014;26:549–552. doi: 10.1589/jpts.26.549. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 31.Sullivan MJ, Simon G. A telephonic intervention for promoting occupational re-integration in work-disabled individuals with musculoskeletal pain. Transl Behav Med. 2012;2:149–158. doi: 10.1007/s13142-012-0119-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32*.Bergbom S, Flink IK, Boersma K, Linton SJ. Early psychologically informed interventions for workers at risk for pain-related disability: does matching treatment to profile improve outcome? J Occup Rehabil. 2014;24:446–457. doi: 10.1007/s10926-013-9478-1. Randomized controlled trial of Activity Training (e.g., goal setting, individually designed activity plans), Cognitive Behavior Therapy (e.g., problem solving, pacing, stress management), or Graded Exposure In-Vivo (e.g., individual hierarchy of feared movements, graded exposure) for low back pain among workers who had not used long-term disability benefits (N = 101). Results indicated that all three interventions were efficacious for reducing fear-avoidance beliefs, self-reported disability, and pain intensity both immediately after treatment and at 9-month follow-up. [DOI] [PubMed] [Google Scholar]
  • 33.Domenech J, Sanchis-Alfonso V, Espejo B. Changes in catastrophizing and kinesiophobia are predictive of changes in disability and pain after treatment in patients with anterior knee pain. Knee Surg Sports Traumatol Arthrosc. 2014;22:2295–3000. doi: 10.1007/s00167-014-2968-7. [DOI] [PubMed] [Google Scholar]
  • 34.Robinson JP, Theodore BR, Dansie EJ, Wilson HD, Turk DC. The role of fear of movement in subacute whiplash-associated disorders grades I and II. Pain. 2013;154:393–401. doi: 10.1016/j.pain.2012.11.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.de Jong JR, Vlaeyen JWS, 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;153:2109–2118. doi: 10.1016/j.pain.2012.07.001. [DOI] [PubMed] [Google Scholar]
  • 36.Riecke J, Holzapfel S, Rief W, Glombiewski JA. Evaluation and implementation of graded in vivo exposure for chronic low back pain in a German outpatient setting: a study protocol of a randomized controlled trial. Trials. 2013;14:203. doi: 10.1186/1745-6215-14-203. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Raftery MN, Murphy AW, O’Shea E, Newell J, McGuire BE. Effectiveness of a cognitive behavioural therapy-based rehabilitation programme (Progressive Goal Attainment Program) for patients who are work-disabled due to back pain: study protocol for a multicentre randomised controlled trial. Trials. 2013;14:290. doi: 10.1186/1745-6215-14-290. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Rolving N, Oestergaard LG, Willert MV, Christensen FB, Blumensaat F, Bunger C, Nielsen CV. Description and design considerations of a randomized clinical trial investigating the effect of a multidisciplinary cognitive-behavioural intervention for patients undergoing lumbar spinal fusion surgery. BMC Musculoskelet Disord. 2014;15:62. doi: 10.1186/1471-2474-15-62. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Asmundson GJ, Parkerson HA, Petter M, Noel M. What is the role of fear and escape/avoidance in chronic pain? Models, structural analysis and future directions. Pain Manag. 2012;2:295–303. doi: 10.2217/pmt.12.15. [DOI] [PubMed] [Google Scholar]
  • 40.Connolly FR, Aitken LM, Tower M. An integrative review of self-efficacy and patient recovery post acute injury. J Adv Nurs. 2014;70:714–728. doi: 10.1111/jan.12237. [DOI] [PubMed] [Google Scholar]
  • 41.Gonzalez A, Hogan J, McLeish AC, Zvolensky MJ. An evaluation of pain-related anxiety among daily cigarette smokers in terms of negative and positive reinforcement smoking outcome expectancies. Addict Behav. 2010;35:553–557. doi: 10.1016/j.addbeh.2010.01.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Patterson AL, Gritzner S, Resnick MP, Dobscha SK, Turk DC, Morasco BJ. Smoking cigarettes as a coping strategy for chronic pain is associated with greater pain intensity and poorer pain-related function. J Pain. 2012;13:285–292. doi: 10.1016/j.jpain.2011.11.008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Ditre JW, Zale EL, Kosiba JD, Zvolensky MJ. A pilot study of pain-related anxiety and smoking-dependence motives among persons with chronic pain. Exp Clin Psychopharmacol. 2013;21:443–449. doi: 10.1037/a0034174. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44*.Ditre JW, Langdon KJ, Kosiba JD, Zale EL, Zvolensky MJ. Relations between pain-related anxiety, tobacco dependence, and barriers to quitting among a community-based sample of daily smokers. Addict Behav. 2015;42:130–135. doi: 10.1016/j.addbeh.2014.11.032. Approximately 17% of daily smokers recruited from the community endorsed moderate-to-severe past-month pain. Results indicated that pain-related anxiety was independently associated with greater tobacco dependence and barriers to smoking cessation, even after accounting for pain intensity, gender, and the presence of a current anxiety, mood, or substance use disorder. These findings provide support for the notion that pain-related anxiety may be an important mechanism in associations between tobacco smoking and chronic pain. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Ditre JW, Brandon TH, Zale EL, Meagher MM. Pain, nicotine, and smoking: Research findings and mechanistic considerations. Psychol Bull. 2011;137:1065–1093. doi: 10.1037/a0025544. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Hooten WM, Shi Y, Gazelka HM, Warner DO. The effects of depression and smoking on pain severity and opioid use in patients with chronic pain. Pain. 2011;152:223–229. doi: 10.1016/j.pain.2010.10.045. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 47.Hogan J, Gonzalez A, Howell A, Bonn-Miller MO, Zvolensky MJ. Pain-related anxiety and marijuana use motives: a pilot test among active marijuana-using young adults. Cogn Behav Ther. 2010;39:283–292. doi: 10.1080/16506073.2010.505247. [DOI] [PubMed] [Google Scholar]
  • 48*.Egli M, Koob GF, Edwards S. Alcohol dependence as a chronic pain disorder. Neurosci Biobehav Rev. 2012;36:2179–2192. doi: 10.1016/j.neubiorev.2012.07.010. Reviews associations between chronic pain and alcohol use disorder, with a focus on neurobiological mechanisms of action. Provides evidence that chronic pain and alcohol dependence share overlapping neural substrates, and proposes an allostatic load model by which repeated episodes of both pain and alcohol intoxication/withdrawal may result in pathological changes to neural structure and function. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Zale EL, Maisto SA, Ditre JW. Interrelations between pain and alcohol: An integrative review. Clin Psychol Rev. doi: 10.1016/j.cpr.2015.02.005. in press. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Arnow BA, Hunkeler EM, Blasey CM, Lee J, Constantino MJ, Fireman B, Kraemer HC, Dea R, Robinson R, Hayward C. Comorbid depression, chronic pain, and disability in primary care. Psychosom Med. 2006;68:262–268. doi: 10.1097/01.psy.0000204851.15499.fc. [DOI] [PubMed] [Google Scholar]
  • 51.Dersh J, Polatin PB, Gatchel RJ. Chronic pain and psychopathology: research findings and theoretical considerations. Psychosom Med. 2002;64:773–786. doi: 10.1097/01.psy.0000024232.11538.54. [DOI] [PubMed] [Google Scholar]
  • 52.McWilliams LA, Cox BJ, Enns MW. Mood and anxiety disorders associated with chronic pain: an examination in a nationally representative sample. Pain. 2003;106:127–133. doi: 10.1016/s0304-3959(03)00301-4. [DOI] [PubMed] [Google Scholar]
  • 53.Rusu AC, Pincus T, Morley S. Depressed pain patients differ from other depressed groups: Examination of cognitive content in a sentence completion task. PAIN. 2012;153:1898–1904. doi: 10.1016/j.pain.2012.05.034. [DOI] [PubMed] [Google Scholar]
  • 54.Wong WS, Lam HM, Chen PP, Chow YF, Wong S, Lim HS, Jensen MP, Fielding R. The Fear-Avoidance Model of Chronic Pain: Assessing the Role of Neuroticism and Negative Affect in Pain Catastrophizing Using Structural Equation Modeling. Int J Behav Med. 2014 doi: 10.1007/s12529-014-9413-7. [DOI] [PubMed] [Google Scholar]
  • 55.Knaster P, Karlsson H, Estlander A-M, Kalso E. Psychiatric disorders as assessed with SCID in chronic pain patients: the anxiety disorders precede the onset of pain. Gen Hosp Psychiatry. 2012;34:46–52. doi: 10.1016/j.genhosppsych.2011.09.004. [DOI] [PubMed] [Google Scholar]
  • 56.de Heer EW, Gerrits MM, Beekman AT, Dekker J, van Marwijk HW, de Waal MW, Spinhoven P, Penninx BW, van der Feltz-Cornelis CM. The association of depression and anxiety with pain: a study from NESDA. PLoS One. 2014;9:e106907. doi: 10.1371/journal.pone.0106907. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES