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…)