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Fear-Avoidance Model of Chronic Pain: The Next Generation
Open accessAbstract
OBJECTIVE: 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. METHODS: A narrative review. RESULTS: 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. DISCUSSION: 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.
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“However, the assumptions that underlie these paradigms and models remain often untested for chronic pain [3,5].”
From Attentional bias and chronic pain: Where to go from here? (2014) · cites this paper as [3]
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.
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“Multiple authors have pointed out the lack of other relevant psychological phenomena such as motivation (Crombez et al., 2012), associative learning (Krypotos et al., 2022;Vlaeyen, 2015), attentionregulation (Boselie & Vlaeyen, 2017;Crombez et al., 2012), personality (Crofford, 2015;Goubert et al., 2004;Wong et al., 2015), trauma (Afari et al., 2014), and social relationships (Edwards et al., 2016”
From Beyond yellow flags: The Big‐Five personality traits and psychologically informed musculoskeletal rehabilitation. (2023) · cites this paper as Crombez et al., 2012
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 [17]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“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 [67]
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“It is worth noting that fear avoidance limits the opportunity to attune expectations to actual experiences, leading to long-term disability [79].”
From Virtual Reality–Based Training in Chronic Low Back Pain: Systematic Review and Meta-Analysis of Randomized Controlled Trials (2024) · cites this paper as [79]
In the citing paper
“It is also associated with elevated pain severity and disability among abuse victims 73, 74.”
From Evaluating psychosocial contributions to chronic pain outcomes (2018) · cites this paper as [73]
In the citing paper
“As a recent review of the model clarifies, 'at the core of the FA model is how patients interpret pain' (p 476) 12 and changing these interpretations is the key process of change within this approach.”
From The Psychological Flexibility Model: A Basis for Integration and Progress in Psychological Approaches to Chronic Pain Management (2014) · cites this paper as [12]
In the citing paper
“Recently some of those involved in the development of the FA model proposed that it needs to meet several important challenges and that this would create a next generation of the model. 12”
From The Psychological Flexibility Model: A Basis for Integration and Progress in Psychological Approaches to Chronic Pain Management (2014) · cites this paper as [12]
In the citing paper
“Three primary elements of the model were identified as lacking: (a) a model of normal psychological processes rather than pathological ones, (b) a proposal for how recovery from fear and avoidance is to occur, and (c) appreciation of the context of multiple goals, meaning, in their words, that 'pain-related fear and avoidance cooccur [sic] in a context of multiple and often competing goals.' 12”
From The Psychological Flexibility Model: A Basis for Integration and Progress in Psychological Approaches to Chronic Pain Management (2014) · cites this paper as [12]
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Self-citation
Metadata
- Authors
- Crombez, G., Eccleston, C., Van Damme, S., Vlaeyen, J. W. S., & Karoly, P.
- Affiliations
- Ghent University (BE)
- KU Leuven (BE)
- Maastricht University (NL)
- Arizona State University (US)
- Corresponding author
- Crombez, Geert
- Venue
- The Clinical Journal of Pain
- Published
- 2012-07
- Volume
- 28
- Issue
- 6
- Pages
- 475-483
- ISSN
- 0749-8047 (ISSN-L)
- OpenAlex
- W2091637698
- Cited by
- 960
- References
- 116
- Citations by year
- 2026: 65 · 2025: 67 · 2024: 80 · 2023: 75 · 2022: 73 · 2021: 79 · 2020: 83 · 2019: 65 · 2018: 78 · 2017: 59 · 2016: 63 · 2015: 59 · 2014: 59 · 2013: 36 · 2012: 14
- FWCI
- 6.22
- Type
- journal article
- Language
- en
- Open access
- green
- biblio.ugent.be
- Licence
- other-oa
- Locations
- Clinical Journal of Pain (publishedVersion)
- PubMed (publishedVersion)
- Ghent University Academic Bibliography (Ghent University) (submittedVersion, other-oa)
- Lirias (KU Leuven) (submittedVersion, other-oa)
- Funders
- Fonds Wetenschappelijk Onderzoek
- Universiteit Gent (BOF-GOA2006/001)
- 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 pain, fear of pain, avoidance behavior, disability, functional recovery, goals, self-regulation, psychopathology
- MeSH terms
- Anxiety, Avoidance Learning, Fear, Forecasting, Humans, Models, Psychological, Chronic Pain
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