The fear-avoidance model of musculoskeletal pain: Current state of scientific evidence
Open accessAbstract
Research studies focusing on the fear-avoidance model have expanded considerably since the review by Vlaeyen and Linton (Vlaeyen J. W. S. & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain, 85(3), 317--332). The fear-avoidance model is a cognitive-behavioral account that explains why a minority of acute low back pain sufferers develop a chronic pain problem. This paper reviews the current state of scientific evidence for the individual components of the model: pain severity, pain catastrophizing, attention to pain, escape/avoidance behavior, disability, disuse, and vulnerabilities. Furthermore, support for the contribution of pain-related fear in the inception of low back pain, the development of chronic low back pain from an acute episode, and the maintenance of enduring pain, will be highlighted. Finally, available evidence on recent clinical applications is provided, and unresolved issues that need further exploration are discussed.
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Chronic pain psychological interventions have substantial empirical backing over many years.
“Psychological interventions for chronic pain have a longstanding history of empirical support.26 Support for psychological approaches can be found in both systematic reviews18,29,33 and meta-analyses.22,45”
From A Comparative Meta-Analysis of Unidisciplinary Psychology and Interdisciplinary Treatment Outcomes Following Acceptance and Commitment Therapy for Adults with Chronic Pain. (2020) · cites this paper as [29]
The “Effectiveness of Cognitive Behavioral Programs” section reviews studies from 1999–2006 and reports that cognitive-behavioral programs can reduce disability, supporting an established empirical basis for some psychological approaches. Its discussion focuses on musculoskeletal pain and particular interventions, however, rather than documenting longstanding support for psychological interventions across chronic pain generally. No page number is available in our copy. (LLM, conf=0.82)
Experimental — accuracy not yet measuredMSK providers have addressed the mental factors that influence pain using three primary frameworks: the fear-avoidance model, pain neuroscience education and cognitive behavioural therapy (CBT).
“Musculoskeletal (MSK) providers have addressed the mental factors that influence pain using three primary frameworks: the fear-avoidance model, pain neuroscience education and cognitive behavioural therapy (CBT) (Archer et al., 2016;Chimenti et al., 2018;Leeuw et al., 2007;Moseley & Vlaeyen, 2015;Stearns et al., 2021).”
From Beyond yellow flags: The Big‐Five personality traits and psychologically informed musculoskeletal rehabilitation. (2023) · cites this paper as Leeuw et al., 2007
The paper is a review of the fear-avoidance model, and its “Effectiveness of Cognitive Behavioral Programs” section discusses treatments targeting pain-related fear and catastrophizing. The passages do not identify pain neuroscience education or establish that the three named approaches are the primary frameworks used by MSK providers. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThese models identify key psychological constructs (yellow flags) such as pain catastrophizing, kinesiophobia, pain anxiety, depression, pain avoidance and low pain self-efficacy which are associated with poor long-term MSK health outcomes.
“These models identify key psychological constructs (yellow flags) such as pain catastrophizing, kinesiophobia, pain anxiety, depression, pain avoidance and low pain self-efficacy which are associated with poor long-term MSK health outcomes (Leeuw et al., 2007;Lentz et al., 2016;Martinez-Calderon et al., 2019;Stearns et al., 2021;Van Wyngaarden et al., 2019).”
From Beyond yellow flags: The Big‐Five personality traits and psychologically informed musculoskeletal rehabilitation. (2023) · cites this paper as Leeuw et al., 2007
The Pain-Related Fear as a Risk Factor for the Development of Chronic LBP section (page unavailable) reports that pain catastrophizing and pain-related fear are associated with later chronic low-back pain and disability. The Vulnerabilities section also links catastrophizing, fear, depression and disability. However, our copy does not identify low pain self-efficacy as a construct in the fear-avoidance model; it appears in a cited reference, and the prospective findings presented are chiefly about low-back pain rather than all long-term musculoskeletal outcomes. (LLM, conf=0.86)
Experimental — accuracy not yet measuredFear can cause avoidance behaviors even in the absence of pain, creating a cycle of inactivity and disability, as described in the Fear-Avoidance Model.
“This fear can cause avoidance behaviors even in the absence of pain, creating a cycle of inactivity and disability, as described in the Fear-Avoidance Model.16, 17, 18”
From Role of Anxiety in Individuals with Generalized Joint Hypermobility: A Systematic Review (2025) · cites this paper as [18]
The Fear-Avoidance Model of Pain and Pain-Related Fear as a Maintaining Factor of CLBP sections describe fear-driven avoidance that can promote disability and disuse. The Escape/Avoidance Behavior section also describes avoiding activities expected to increase pain, but the paper does not establish that this cycle occurs in the absence of pain; its account concerns people experiencing pain. Page numbers are unavailable in our copy. (LLM, conf=0.85)
Experimental — accuracy not yet measuredAccording to the fear-avoidance model, pain catastrophizing is a crucial cognitive variable involved in emotional distress and impairment associated with pain experience.
“According to the influential fear-avoidance model of chronic pain (Leeuw et al. 2007;Vlaeyen and Linton 2012), pain catastrophizing is a crucial cognitive variable involved in emotional distress and impairment associated to pain experience.”
From Efficacy of Combined Cognitive-Behavioral Therapy for Insomnia and Pain in Patients with Fibromyalgia: A Randomized Controlled Trial (2018) · cites this paper as Leeuw et al. 2007
The Fear-Avoidance Model describes core cognitive-behavioural processes, including pain catastrophising, pain-related fear, pain hypervigilance and pain avoidance, which contribute to the transition from acute to persistent pain, including maintaining and exacerbating processes.
“The Fear-Avoidance Model (FAM)65–71 describes core cognitive–behavioural processes, including pain catastrophising, pain-related fear, pain hypervigilance and pain avoidance, which contribute to the transition from acute to persistent pain, including maintaining and exacerbating processes.”
From Optimising psychological treatment for pain after breast cancer: a factorial design study protocol in Denmark (2023) · cites this paper as [66]
Prior reviews and meta-analyses of psychological approaches have mixed unidisciplinary and interdisciplinary treatments, potentially complicating interpretation.
“Thus far, the reviews and meta-analyses regarding psychological approaches.18,22,29,33,45 have included a mix of both types of treatment, which may be a complicating factor with regard to interpretation of findings.”
From A Comparative Meta-Analysis of Unidisciplinary Psychology and Interdisciplinary Treatment Outcomes Following Acceptance and Commitment Therapy for Adults with Chronic Pain. (2020) · cites this paper as [29]
The “Effectiveness of Cognitive Behavioral Programs” section discusses programs with various techniques, but it does not say that prior reviews or meta-analyses mixed unidisciplinary and interdisciplinary treatments or that such mixing complicated interpretation. Searches for those treatment categories and the proposed interpretation problem found no passage addressing the claim; page numbers were not available in our copy. (LLM, conf=0.74)
Experimental — accuracy not yet measuredPain catastrophizing is linked to problems that impede recovery, complicate treatment, and raise the risk of persistent pain and disability.
“Not surprisingly, pain catastrophizing is associated with a variety of problems that hinder recovery, making treatment more difficult and increasing the risk of developing persistent pain and disability.6,9,22”
From Impact of psychological factors in the experience of pain (2011) · cites this paper as [9]
Vigilance, an abnormal focus on possible pain or injury signals, might explain why a small injury causes intense pain.
“Vigilance refers to an abnormal focus on possible signals of pain or injury 9 that might help explain why a seemingly small injury results in intense pain.”
From Impact of psychological factors in the experience of pain (2011) · cites this paper as [9]
According to the fear-avoidance model of pain, aggravation of symptomatology and disability in the presence of pain occurs when individuals catastrophize about their pain experience.
“For example, according to the fear-avoidance model of pain, aggravation of symptomatology and disability in the presence of pain occurs when individuals catastrophize about their pain experience [12].”
In chronic low back pain, fear of pain is more disabling than pain itself.
“There is accumulating evidence that in chronic low back pain, fear of pain is more disabling than pain itself [13,14].”
From The fidelity of treatment delivery can be assessed in treatment outcome studies: a successful illustration from behavioral medicine (2009) · cites this paper as [14]
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- Authors
- Leeuw, M., Goossens, M. E. J. B., Linton, S. J., Crombez, G., Boersma, K., & Vlaeyen, J. W. S.
- Affiliations
- Maastricht University (NL)
- Örebro University (SE)
- Ghent University (BE)
- Maastricht University Medical Centre (NL)
- Corresponding author
- Leeuw, Maaike
- Venue
- Journal of Behavioral Medicine
- Published
- 2006-12-20
- Volume
- 30
- Issue
- 1
- Pages
- 77-94
- ISSN
- 0160-7715 (ISSN-L)
- 1573-3521
- OpenAlex
- W2127113745
- Cited by
- 2,261
- References
- 206
- Citations by year
- 2026: 108 · 2025: 110 · 2024: 115 · 2023: 116 · 2022: 143 · 2021: 130 · 2020: 133 · 2019: 121 · 2018: 148 · 2017: 141 · 2016: 133 · 2015: 148 · 2014: 111 · 2013: 126 · 2012: 115
- FWCI
- 5.55
- Type
- journal article
- Language
- en
- Open access
- green
- lirias.kuleuven.be
- Licence
- other-oa
- www.springer.com/tdm (tdm)
- Locations
- Journal of Behavioral Medicine (publishedVersion)
- PubMed (publishedVersion)
- Research Publications (Maastricht University) (publishedVersion)
- Lirias (KU Leuven) (submittedVersion, other-oa)
- Ghent University Academic Bibliography (Ghent University) (submittedVersion)
- Research Publications (Maastricht University) (submittedVersion)
- Funders
- ZonMw
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Pediatric Pain Management Techniques
- Keywords
- fear-avoidance model, chronic musculoskeletal pain, low back pain, pain catastrophizing, fear of pain, disability, disuse, pain intensity, attention to pain, pain maintenance, cognitive-behavioral model
- MeSH terms
- Affect, Anxiety, Attention, Chronic Disease, Escape Reaction, Fear, Humans, Motor Activity, Musculoskeletal Diseases, Pain, Cognitive Behavioral Therapy, Muscular Disorders, Atrophic
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