Pain-related anxiety and avoidance: a practical application of theory and research to clinical practice

In 1995 I started work at the Burwood Pain Management Centre.  It wasn’t my first foray into pain management, but it was the first time I had worked in a fully integrated interdiscipinary team environment.  It was also significant because of the use of the words ‘fear-avoidance’, ‘guarding’ and ‘anticipatory anxiety’.

What the team had observed was that there were a specific group of patients who were not just worried about experiencing pain, but were also showing the signs of increased physiological arousal, avoidance of specific activities, and firm beliefs about harm, reinjury, or doing further damage.

At the time we used an operant conditioning model (based on Fordyce, 1971 & 1976), along with graded reactivation using a physical conditioning model, to help these people learn to be more functional.  We had some successes – but a number of less successful responses too.

Towards the end of the 1990’s, a new model started to emerge.  It was the ‘fear-avoidance’ model proposed firstly by Lethem et al (Lethem et al. 1983), then elaborated on by Vlaeyen and colleagues (1999, 2000).

This model proposed that people demonstrating avoidance of activities may be developing a ‘phobic’ response to their situation: based on catastrophic interpretations of their pain, beliefs that their body will be dangerously harmed by movements, increased physiological arousal in response to these beliefs, avoidance of situations the same as or similar to those that provoke their beliefs, and subsequent reward of this avoidance by negative reinforcement (ie, by avoiding a negative experience, they increase the avoidance behaviour).

Later, using an exposure therapy approach developed from the treatment of other anxiety disorders such as spider phobia or panic disorder, Johan Vlaeyen and colleagues (2001) demonstrated that it was possible to reduce avoidance behaviour, and improve both function and reported pain intensity.

Since then, exposure-based approaches to reducing avoidance of feared activities has become increasingly popular.  At Pain Management Centre, occupational therapists, physiotherapists and psychologists use graded exposure as one of several ways to help people with chronic pain, high avoidance and fear of harm to learn to tolerate feared activities.

We haven’t completely stopped using an operant model – we’ve refined how we use it, we’ve started to identify those for whom it’s less appropriate, and we have integrated other models, like the pain-related anxiety and avoidance model (and its management using graded exposure).  We still use behavioural approaches like recording and graphing and monitoring progress; and we integrate cognitive strategies such as imagery, education, reframing, positive self statements and so on – all of which have been part of our range of strategies for many years.

What we’re learning is that for some people who demonstrate certain characteristics, a graded exposure approach seems to provide a really good response.  The characteristics? high scores on the Tampa Kinesiophobia Scale; low activity level; increased physiological arousal when asked to carry out feared activities, or avoidance of these activities; specific fears of harm or damage if the movements are carried out.

So, a theory is applied to a phenomenon that is often observed.  Drawing from previous research in another, but related area, a therapeutic approach is recommended.  It is then used, and gradually a body of evidence grows to support its use for certain people who present in specific ways.

This is why I love theory – real research questions about real people with real problems, and a way of organising information that help us learn how to help them!

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I’m away for a few days (no Friday funnies!), but I’ll be back on Monday.  Have a wonderful weekend!

Fordyce, W. E. (1971). Behavioral methods in rehabilitation. In W. S. Neff
(Ed.), Rehabilitation psychology (pp. 74–108). Washington, DC: American
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Fordyce, W. E. (1976). Behavioral methods in chronic pain and illness. St.
Louis, MO: Mosby.

Lethem J, Slade PD, Troup JDG, Bentley G. (1983). Outline of fear-avoidance model
of exaggerated pain perceptions. Behaviour Research and Therapy;
21: 401-408.

Vlaeyen, J. W., & Crombez, G. (1999). Fear of movement/(re)injury, avoidance and pain disability in chronic
low back pain patients.[see comment]. Manual Therapy., 4(4), 187-195.

Vlaeyen, J. W., de Jong, J., Geilen, M., Heuts, P. H., & van Breukelen, G. (2001). Graded exposure in vivo in the treatment of pain-related fear: a replicated single-case experimental design in four patients with chronic low back pain. Behaviour Research & Therapy., 39(2), 151-166.

Vlaeyen, J. W., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain., 85(3), 317-332.

Vlaeyen, J. W., Seelen, H. A., Peters, M., de Jong, P., Aretz, E., Beisiegel, E., et al. (1999). Fear of movement/(re)injury and muscular reactivity in chronic low back pain patients: an experimental investigation. Pain., 82(3), 297-304.