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). (more…)

A randomized controlled trial of exposure in vivo for patients with spinal pain reporting fear of work-related activities


The complex question of whether to integrate experimental therapeutic interventions into daily clinical practice is one that has caught many therapists out. A case in point is the use of laterality and visualised movements for CRPS where, in one clinic, it was found that of the 10 participants recruited, only 4 had actually adhered to the treatment protocol, none of these demonstrated changes to their function or reported pain.

A treatment with more experimental support than laterality training for CRPS is graded exposure for pain-related anxiety and fear in people with low back pain.

This study by Linton, et al. (2008), is an excellent example of how careful description of process and equally careful monitoring and measurement can provide insights into how to transfer promising experimental findings into clinical practice. As the authors state: “Pain-related fear is a key factor in the perpetuation of back pain disability for a subgroup of patients with work-related pain problems (Asmundson et al., 2004; Leeuw et al., in press; Vlaeyen and Linton, 2000).” Previous studies by Vlaeyen and others have demonstrated the effectiveness of an exposure-based approach to reduce the fear and disability experienced by people scoring above >35 on the TSK (Boersma et al., 2004; de Jong et al., 2005a,b; Linton et al., 2002; Vlaeyen et al., 2001). The process involves assessing specific activities that the individual identifies as causing concern using the PHODA Photograph Series of Daily Activities (PHODA) (Kugler et al., 1999), developing a graded hierarchy of activities, then working through this hierarchy until the individual no longer experiences concern at these activities.

This study extends the research by employing a randomised controlled trial, with waitlist control group, and treatment as usual carried out at the same time as the graded exposure. Treatment as usual consisted of medication, contact with the GP and physiotherapy (the content of physiotherapy was not specified). Quite stringent criteria were used for inclusion, leading to a small treatment group (46 out of 223 potential participants), and a high drop-out rate also influenced results although this was controlled for using intention to treat methodology. The drop-out rate is similar to that found in other exposure-based treatments for other disorders (eg OCD), and probably reflects the difficulty of the task – facing very real fears is never easy!

Something that this study included that other exposure-based studies have not, is attention to work-specific concerns. The basis for this is that many people with ongoing disability report their fear of being able to sustain activities at work, while they may continue to participate in home-based activities. The study does not specify the type of work these participants were engaged in, which is a short-coming, and the authors say ‘Because this study was not specifically designed to assess fear of work movements, future studies will be needed to ascertain whether fear may be specific to work movements as well as whether the addition of exposure for work movements/situations is of real value.’ The PHODA does not identify work-specific activities, but instead uses a range of daily home and community-based activities, and I can envisage some challenges in developing a research appropriate work task assessment tool similar to the PHODA simply because of the wide range of work activities. Phobia’s are incredibly personal, unique and specific fears, and stimuli for eliciting fear need to be just as unique, which will be a challenge for research. In my practice, photographs or video of the actual workplace has been used, which provides some degree of authenticity to the initial stimulus.

The results? Overall, it was found that exposure therapy did have an effect, but given both the limitations of a waitlist design, and the relatively high threshold for inclusion, it may be difficult to justify exposure therapy as a standalone treatment. It seems to have effect when included with treatments addressing family, employer, cognitive beliefs and other work rehabilitation barriers, alongside functional activity.

Perhaps, when occupational therapists and psychologists start to talk to each other, and trust each others clinical skills, both they and physiotherapists may be able to develop treatment protocols to help transfer exposure therapy into settings such as work – although I value the work of therapy in clinic, it seems that with treatment of phobia, it’s not enough to do this only in a clinic setting and the ‘real life’ setting of work, home and the community needs to be used as an integral part of therapy.

Asmundson GJ, Vlaeyen JWS, Crombez G. Understanding and treating fear of pain. Oxford, England: Oxford University Press; 2004.

Boersma K, Linton SJ, Overmeer T, Janson M, Vlaeyen JWS, de Jong. Lowering fear-avoidance and enhancing function through exposure in vivo: a multiple baseline study across six patients with back pain. Pain 2004;108:8–16.

de Jong JR, Vlaeyen JW, Onghena P, Cuypers C, den Hollander M, uijgrok J. Reduction of pain-related fear in complex regional pain syndrome type I: the application of graded exposure in vivo. Pain 2005a;116:264–75.

de Jong JR, Vlaeyen JW, Onghena P, Goossens ME, Geilen M, Tulder H. Fear of movement/(re)injury in chronic low back pain:education or exposure in vivo as mediator to fear reduction? Clin J Pain 2005b;21:9–17.

Kugler K, Wijn J, Geilen M, de Jong J, Vlaeyen JWS. The photograph series of daily activities (PHODA). The Netherlands: Heerlen; 1999.

Vlaeyen JWS, de Jong J, Geilen M, Heuts PHTG, van Breukelen G.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. Behav Res Ther 2001;39:151–66.

Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain


LINTON, S. (2007). A randomized controlled trial of exposure in vivo for patients with spinal pain reporting fear of work-related activities. European Journal of Pain DOI: 10.1016/j.ejpain.2007.11.001

Are you afraid to push your patients?

We have all heard about fear avoidance, or pain-related anxiety and avoidance in patients (Vlaeyen & Linton, 2000). This model of pain disability has become increasingly prominent over the past 10 years and research has demonstrated its effectiveness in predicting those who will develop long-standing disability, as well as providing amodel for treatment approaches – the graded exposure approach being one (Vlaeyen, 2002; Leeuw, Goossens, van Breukelen, deJong, Heuts, Smeets, Koke, Vlaeyen, 2008)).

Shortly after the model was introduced, researchers posed the question – are we as clinicians fear avoidant? Do we avoid asking our patients to ‘push’ themselves – either into increasing pain, or possible harm? (Linton, Vlaeyen, Ostelo (2002) is a good example).

In this recent editorial, Ostelo and Vlaeyen (2008) ask the question: have things changed? Do we still limit our expectations of people who experience pain because of our own beliefs and attitudes? Do we project our own concerns onto our patients, and in so doing, increase their risk of ongoing disability?

Bishop, Foster, Thomas & Hay (2008) suggest in their study that indeed, our treatment behaviour is correlated with our personal beliefs and attitudes, and that this affects our expectations and recommendations for our patients. Although there are several criticisms of that study (low response rate, yet another questionnaire with relatively little cross-validation of the content, and the use of vignettes rather than observing actual clinical practice), it nevertheless raises questions that haven’t previously been asked about the influences on patients, rather than focusing only on patient beliefs and attitudes.

It’s not an easy area to study, but intriguing, and opens the fear avoidance model up to include more environmental factors than are currently included. So, a question for all of us: how do we feel about asking patients to persist with activities despite pain? What do we do – both intentionally in terms of recommendations, and unintentionally in terms of our verbal and nonverbal behaviour?

Ostelo R.W.J.G & Vlaeyen J.W.S.(2008) Attitudes and beliefs of health care providers: Extending the fear-avoidance model Pain (135:1-2), pp 2-3.

It’s not enough just to feel – it’s about ‘what do you feel?’


Pain. 2007 Dec 1

Tactile discrimination, but not tactile stimulation alone, reduces chronic limb pain.

Moseley GL, Zalucki NM, Wiech K

This interesting study by the prolific Lorimer Moseley suggests that it’s not good enough for people with complex regional pain syndrome to just be exposed to tactile stimuli, but they need to do something with that stimulus for it to translate into changes in pain intensity and ability to discriminate.
This study was a four phase (A–B–C–D) within subjects repeated measures design. The first phase was a no-treatment waiting period. The second phase was the stimulation only condition. The third phase was the discrimination condition. The duration of each of these phases was between 11 and 17 days (randomly allocated for each participant). The fourth phase was a three-month follow-up period.
The stimulation only condition involved On a digital photograph of the affected limb, five points were marked Two cork probes (2 and 11 mm in diameter, respectively) were mounted atop a spring-loaded cartridge such that the pressure with which each probe could be applied to the skin was standardised.A screen was positioned to prevent the subject from seeing the affected area. Stimulation involved applying one of the probes to one of the marked points. The type of probe and the marked point were randomised using a random numbers table. Interstimulus interval was 15 s. Three 6-min blocks of 24 stimuli were undertaken with a 3-min rest period between blocks. Thus, each treatment session involved 72 stimuli and lasted 24 min, and was repeated every week day.
The discrimination phased was exactly the same, however, participants were given a photograph of their limb on which the stimulation points were marked. They were also shown the two probes. During the tactile stimulation, participants responded to each stimulus by stating (i) the location of the stimulus (i.e. the corresponding number on the photograph) and (ii) the type of probe.
The effect of tactile stimulation and discrimination on function (task-specific NRS)Tasks selected by each participant reflected the body part that was affected. For example, most participants selected sleeping; most participants with CRPS of the upper limb selected ‘dressing’, ‘eating’ and ‘driving’; participants with CRPS of the dominant upper limb selected ‘writing’ or ‘using my hand’; all participants with CRPS of the lower limb selected ‘walking’ and ‘wearing a shoe’.At baseline, means ± SD function score was 2.2 ± 0.8. Function changed over the course of the study (main effect of time; (F(4, 48) = 70.05, p < 0.001). Pairwise comparisons revealed that there was no change in function during the stimulation phase [mean (95% CI) = 3.1 (2.0–4.1)], nor during the waiting period [2.5 (1.9–3.2); p > 0.34 for both)]. Function was higher at post-discrimination [5.5 mm (34–38 mm)] than it was at post-stimulation, post-waiting period or at baseline (p < 0.001 for all). The mean (95% CI) effect size for the function score was 1.9 (1.1–2.8). Function had not changed further at follow-up [5.5 (4.5–6.5), p = 0.98], but it was still higher than it was at post-stimulation, post-waiting period or at baseline (p < 0.001 for all)

Unfortunately, this study was conducted with a group of only 13 people with complex regional pain syndrome, so we don’t know whether it is readily generalisable, but it does provide some food for thought for both occupational therapists and physiotherapists. Both occupational therapists and physiotherapists would argue that goal-directed activities that are relevant to the individual are much more likely to engage the interest and hence ‘motivate’ people to carry them out more readily than ‘exercises’. The challenge has been to identify suitable activities – and to establish why this type of activity should be provided as opposed to the more easily developed ‘exercises’. Now here is a clinical study demonstrating that yes, outcomes can be maximised by engaging the person in active involvement in the activity.

What I really liked about this study was the use of real functional tasks as the ‘ultimate’ measure of whether the intervention worked. Of course it would be great to see a truly randomised study in which an alternative and perhaps competing treatment such as graded exposure is used – I wonder whether by providing an ‘interesting’ activity there is reduction of anxiety and hence more likelihood that the person will use their affected limb. If a really interesting and engaging activity is used in a graded hierarchy, it may prove even more successful. An additional measure to use in this case would be one assessing fear or anxiety about pain, or even one assessing acceptance.

PMID: 18054437 [PubMed – as supplied by publisher]