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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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“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]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“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
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“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
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“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]
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In the citing paper
“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
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“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]
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In the citing paper
“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]
Experimental — accuracy not yet measuredIn the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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 the citing paper
“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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Citations
Cites
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Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art.
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Pinheiro, C. F., Bevilaqua‐Grossi, D., Florêncio, L. L., Bragatto, M. M., Benatto, M. T., Dach, F., BIGAL, M. E., & Carvalho, G. F. (2021) · Physiotherapy Theory and Practice · doi:10.1080/09593985.2021.1996496 · Cited by 15
Terrier, P., Praz, C., Le Carré, J., Vuistiner, P., Léger, B., & Luthi, F. (2019) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-019-2561-9 · Cited by 14
Pain and psychological distress following orthopedic trauma: a call for collaborative models of care
Castillo, R. C., Archer, K. R., Bradford Newcomb, A., & Wegener, S. T. (2016) · Techniques in Orthopaedics · doi:10.1097/bto.0000000000000200 · Cited by 12
Bisby, M. A., Chandra, S. S., Dudeney, J., Scott, A. J., Titov, N., & Dear, B. F. (2023) · Pain Medicine · doi:10.1093/pm/pnac158 · Cited by 13
Zetterqvist, V., Holmström, L., Maathz, P., & Wicksell, R. K. (2017) · Acta Anaesthesiologica Scandinavica · doi:10.1111/aas.12874 · Cited by 13
Bagheri, R., Hedayati, R., Ehsani, F., Hemati-Boruojeni, N., Abri, A., & Taghizadeh Delkhosh, C. (2020) · Journal of Manipulative and Physiological Therapeutics · doi:10.1016/j.jmpt.2019.03.015 · Cited by 10
Bélanger, C., Dumoulin, C., Bergeron, S., Mayrand, M.-H., Khalifée, S., Waddell, G., Dubois, M.-F., PVD Group, & Morin, M. (2022) · The Clinical Journal of Pain · doi:10.1097/ajp.0000000000001030 · Cited by 9
Buskbjerg, C., O'Toole, M. S., Zachariae, R., Jensen, A. B., Frederiksen, Y., Johansen, C., von Heymann, A., Speckens, A., & Johannsen, M. (2023) · BMJ Open · doi:10.1136/bmjopen-2022-066505 · Cited by 4
Scott, R., & Sherod, M. (2019) · Clinical Case Studies · doi:10.1177/1534650119855439 · Cited by 1
Role of Anxiety in Individuals with Generalized Joint Hypermobility: A Systematic Review
van Die-de Vries, J. E., Rameckers, E., Calders, P., Engelbert, R. H., Ramaekers, S. P., Goossens, M. E., & Verbunt, J. A. (2025) · Archives of Rehabilitation Research and Clinical Translation · doi:10.1016/j.arrct.2025.100467 · Cited by 1
Self-citation
Metadata
- 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 › Health Professions › Physical Therapy, Sports Therapy and Rehabilitation › 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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