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!

If you’ve enjoyed this post, and want to read more, you can subscribe using the RSS reader above, or simply bookmark my blog and come back!  I love comments, respond to them readily, and hope you’ll ask questions – it’s good for my learning, and great for sharing in this cyber-community.

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
Psychological Association.
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.


  1. Does your team have a pharmacist? it seems the pharmacist is often left off the team… Maybe it is our fault for sitting on the sidelines too long.

  2. Hi Sandra
    We don’t have a pharmacist on the team any more – we used to, but the hospital pharmacy has cut staffing and doesn’t have time to come to the sessions any more. Our medical team are reasonably au fait with medications but it would be nice to have a pharmacist to discuss medications and interactions with medications (and ‘natural’ supplements) with our patients.

  3. Love the blog – can’t believe how much ‘stuff’ you plough through. Quick question in relation to chronic pain, that I can’t quite get my head around.
    What is your perspective on posture and chronic pain?

    There is so much emphasis on alignment and symmetry, particularly with LBP, yet no real correlation between the two (pain and posture).

    Alexander technique is getting some good press at the moment (as have pilates and ‘core stability’ in the past) yet I’m left wondering if this is more about movement in general – having choices to move towards and away from preferred postures, and those choices being limited due to guarding or anxiety or pain.

    I’m certainly not advocating for special equipment (quite the opposite in fact) but can’t help wondering if we are missing a trick here. If chronic pain indicates a referral to ‘hands off’ physio and the time is spent focussing on the persons posture, aren’t we just re-inforcing the mechanical focus to the patients pain.

    Perhaps 5-10 mins spent encouraging movement in the affected area (eg passive mobilisation) and then applying that gain in functional tasks might offer more success and confidence to the patient. More of a ‘kick-start’ than realigning spines, and with hopefully a more positive message and outcome.

    Just interested in other’s perspectives.


  4. Hi Mary
    Thanks for the compliments!
    Re posture: as far as I can see, there isn’t any specific evidence suggesting that ‘poor’ posture makes any difference – what it does do is limit your options for movement. (Posture being defined as the platform from which you move)
    As far as I know there isn’t any ongoing support directly for pilates, alexander, feldenkrais or any of the ‘core stability’ stuff apart from the generic ‘move it or lose it’ message, and the increased confidence people have when they actually do move…As you point out, it’s about having choices and movement in general!
    I do notice that people with chronic pain become somewhat ‘disassociated’ from their bodies – they don’t seem to experience their bodies-in-space as well as others, so perhaps by bringing focused attention on movement and position, we are actually increasing general awareness and therefore increase confidence?
    Good thinking!

  5. Mmm. Will try and dig out an Alexander Technique reference, that seemed to be going a bit further than that.

    Was discussing the body ‘disassociation’ thing the other day, and had a bit of a lit search. One article looking at repositioning skills (moving a patient away from a position, and then getting them to return there independently) (Asell, 2006) found no difference between a chronic pain group and ‘normal’ population. It might explain why some patients struggle with their physio, but no more than with acute injuries.

    Interesting stuff!

  6. Don’t know if anyone is still responding–this blog is pretty old, but I am experiencing such a problem as addressed here. I had knee surgery, was progressing well with PT, but had an injury which caused great pain and quite a set-back. Since then, I’ve experience extreme anxiety, nausea, etc. just thinking about walking from place to place. I’ve become way too reliant on my crutch, and should certainly be able to walk around my house without it. However, I panic, and freeze up. Deep-breathing can help get me going, but I really need to overcome this–it’s affecting every aspect of my life.
    Glad to know this is a “real” disorder!

    1. I’m really sorry to hear that your pain has given you such a hard time. Anxiety is definitely a significant factor in experiencing pain, and yes it can definitely trigger anxiety attacks like you’ve described. To get help, you can start with long, slow breaths OUT – you’ll always breathe in! – and then open your eyes and place your hands on something and feel your body touching the ground, the support you’re on, and all the other sensations that help your brain remember that you’re safe. Learning good diaphragmatic breathing is probably the first skill to develop before starting on a graduated set of steps to take back what you want from life.
      To set goals for being more independent, start with the first one you’ve mentioned – walking around the house without your crutch. See if you can just walk from one room to another and back without it first. Do this for one week or until you feel more comfortable doing so – remember to use your breathing and let yourself be fully aware that you are bigger than your anxiety. One step at a time. Once you’ve achieved this step, set another goal – maybe walking around your living area without your crutch. Do this in the same way you’ve done the first goal. Then set yourself another goal – maybe to put your crutch by the front door, and not to use it at all inside. But only do this once you begin to feel more confident walking around in one room and walking from room to room.
      If you find this “live” exposure too hard, try first relaxing then using your breathing, begin to imagine yourself walking calmly, tall and confidently. Your mind’s eye is good at this sort of thing so imagine the sensations of walking tall, feeling graceful and confident. If you’re good at visualising, this is when you can imagine seeing yourself walking this way. If you find it easier to “feel the feelings”, imagine the sensations. Make it as vivid as you can in your imagination. Then begin by walking around in one room for maybe an hour without the crutch – and then you’re ready to start the graded exposure above.
      If this is all way too hard, you can see a good occupational therapist with an interest in chronic pain management, or a good clinical psychologist with experience in pain management, or a physiotherapist with experience in graded exposure for chronic pain. It’s always worth asking any health professional about their interest and experience in working in this area, because not all clinicians have the necessary skills to do this kind of work.
      I’d love to know how you get on, drop me a line through the “About” page, and I’ll get it as email.

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