Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art.
Open accessAbstract
In an attempt to explain how and why some individuals with musculoskeletal pain develop a chronic pain syndrome, Lethem et al. (Lethem J, Slade PD, Troup JDG, Bentley G. Outline of fear-avoidance model of exaggerated pain perceptions. Behav Res Ther 1983; 21: 401-408).ntroduced a so-called 'fear-avoidance' model. The central concept of their model is fear of pain. 'Confrontation' and 'avoidance' are postulated as the two extreme responses to this fear, of which the former leads to the reduction of fear over time. The latter, however, leads to the maintenance or exacerbation of fear, possibly generating a phobic state. In the last decade, an increasing number of investigations have corroborated and refined the fear-avoidance model. The aim of this paper is to review the existing evidence for the mediating role of pain-related fear, and its immediate and long-term consequences in the initiation and maintenance of chronic pain disability. We first highlight possible precursors of pain-related fear including the role negative appraisal of internal and external stimuli, negative affectivity and anxiety sensitivity may play. Subsequently, a number of fear-related processes will be discussed including escape and avoidance behaviors resulting in poor behavioral performance, hypervigilance to internal and external illness information, muscular reactivity, and physical disuse in terms of deconditioning and guarded movement. We also review the available assessment methods for the quantification of pain-related fear and avoidance. Finally, we discuss the implications of the recent findings for the prevention and treatment of chronic musculoskeletal pain. Although there are still a number of unresolved issues which merit future research attention, pain-related fear and avoidance appear to be an essential feature of the development of a chronic problem for a substantial number of patients with musculoskeletal pain.
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Pain may enhance learning and memory mechanisms.
“Given the importance of pain and the recognition and avoidance of pain for survival, it is logical that pain may facilitate mechanisms to increase learning and memory (Vlaeyen & Linton, 2000).”
From Feeling and body investigators (FBI): ARFID division—An acceptance-based interoceptive exposure treatment for children with ARFID (2019) · cites this paper as Vlaeyen & Linton, 2000
Section 3 (‘Model 1: the “activity” avoidance model’; page unavailable) describes learning to predict pain and avoid situations associated with it. That supports pain-related avoidance learning, but the paper does not say that pain enhances memory or learning mechanisms generally; a search for memory found no supporting passage. (LLM, conf=0.84)
Experimental — accuracy not yet measuredPain-avoidance learning models may guide ARFID treatment.
“Learning models of pain avoidance may inform ARFID treatment approaches (Vlaeyen & Linton, 2000).”
From Feeling and body investigators (FBI): ARFID division—An acceptance-based interoceptive exposure treatment for children with ARFID (2019) · cites this paper as Vlaeyen & Linton, 2000
Sections 3 and 4 describe learning models of pain avoidance, and Section 13 discusses using the fear-avoidance model to guide treatment for musculoskeletal pain. Our copy does not address ARFID or propose applying the model to its treatment, so that extension is not supported by this source. (LLM, conf=0.86)
Experimental — accuracy not yet measuredEvidence indicates that pain might lead to patterns of behavioral and cognitive avoidance.
“Evidence that pain might lead to patterns of behavioral and cognitive avoidance”
From Psychological aspects of persistent pain: Current state of the science (2004) · cites this paper as [145]
The Conclusions (section 14; page unavailable) describe a model in which pain interpreted as threatening leads to avoidance behaviors. The paper does not establish cognitive avoidance as a parallel pattern; its fear-avoidance model instead predicts hypervigilance to pain-related information (section 4; page unavailable). (LLM, conf=0.83)
Experimental — accuracy not yet measuredPain catastrophizing has a crucial role in the fear avoidance model.
“Pain catastrophizing has a crucial role in the fear avoidance model as it fosters fear-avoidance behaviors, which in turn result in exacerbation of physical and mental symptoms [56,58].”
From The bed nucleus of the stria terminalis as a brain correlate of psychological inflexibility in fibromyalgia (2020) · cites this paper as [58]
The model of fear and avoidance developed for chronic pain describes the forming of a vicious disabling cycle where fear of pain is maintained by avoidance of movement.
“The model of fear and avoidance developed for chronic pain describes the forming of a vicious disabling cycle where fear of pain is maintained by avoidance of movement (Vlaeyen & Linton, 2000).”
From Exposure‐based cognitive behavior therapy for anxiety related to asthma: A feasibility study with multivariate baseline design. (2020) · cites this paper as Vlaeyen & Linton, 2000
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.
“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 [16]
Both clinical and experimental studies suggest that pain-related anxiety and fear are important predictors of how patients adapt to persistent pain.
“Both clinical and experimental studies suggest that pain-related anxiety and fear are important predictors of how patients adapt to persistent pain.145”
From Psychological aspects of persistent pain: Current state of the science (2004) · cites this paper as [145]
Among the psychological constructs that can play an important role in the development and maintenance of chronic pain is catastrophizing.
“Among the psychological constructs that can play an important role in the development and maintenance of chronic pain is catastrophizing [6,23,24].”
Thoughts may change substantially or not very much during treatment and in either case good outcomes can be achieved.
“Thoughts may change substantially or not very much during treatment and in either case good outcomes can be achieved. 13,72,84,85,83”
From The Psychological Flexibility Model: A Basis for Integration and Progress in Psychological Approaches to Chronic Pain Management (2014) · cites this paper as [83]
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 [13]
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- Authors
- Vlaeyen, J. W. S., & Linton, S. J.
- Affiliations
- Maastricht University (NL)
- Örebro University Hospital (SE)
- Corresponding author
- Vlaeyen, Johan W.S.
- Venue
- Pain
- Published
- 2000-04
- Volume
- 85
- Issue
- 3
- Pages
- 317-332
- ISSN
- 0304-3959 (ISSN-L)
- OpenAlex
- W2099093791
- Cited by
- 4,931
- References
- 129
- Citations by year
- 2026: 292 · 2025: 247 · 2024: 213 · 2023: 210 · 2022: 242 · 2021: 263 · 2020: 312 · 2019: 234 · 2018: 231 · 2017: 207 · 2016: 246 · 2015: 210 · 2014: 215 · 2013: 235 · 2012: 196
- FWCI
- 7.39
- Type
- journal article
- Language
- en
- Open access
- green
- lirias.kuleuven.be
- Licence
- other-oa
- Locations
- Pain (publishedVersion)
- PubMed (publishedVersion)
- Lirias (KU Leuven) (submittedVersion, other-oa)
- Brain
- Funders
- Nederlandse Organisatie voor Wetenschappelijk Onderzoek
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
- Health Sciences › Medicine › Physiology › Pain Mechanisms and Treatments
- Keywords
- fear-avoidance model, chronic musculoskeletal pain, fear of pain, pain avoidance, negative affectivity, anxiety sensitivity, hypervigilance, deconditioning, pain prevention, pain management
- MeSH terms
- Chronic Disease, Fear, Humans, Musculoskeletal Diseases, Pain
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