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ROBERT J. GATCHEL, PhD, ABPP1 • RANDY NEBLETT, MA, LPC, BCB2 NANCY KISHINO, OTR/L, CVE3 • CHRISTOPHER T. RAY, PhD, ATC, CSCS4
Fear-Avoidance Beliefs and Chronic Pain J Orthop Sports Phys Ther 2016;46(2):38-43. doi:10.2519/jospt.2016.0601
P
eople are motivated to avoid activities in which they have experienced acute episodes of pain in order to reduce the likelihood of re-experiencing pain or causing further physical damage. This is an adaptive behavioral strategy for dealing with situations involving acute pain, but it can become maladaptive when dealing with chronic pain.11,19,23 The relationship between painrelated fear avoidance (FA) and chronic pain has been studied for over 3 decades, especially in patients with musculoskeletal pain and disability.13 The relationship between fear and pain was first introduced by Lethem and colleagues in 1983.12 Their FA model of exaggerated pain perception proposed that, following an injury, patients would either confront pain (stay active, show a desire to return to work, etc) or avoid pain (resulting in FA, exaggerated pain perception, and eventual physical deconditioning and disability). This model further proposed that fear of pain and avoidance behaviors could become desynchronous from the actual sensory component of pain. Borrowing from Lethem et al12 and incorporating concepts from a number of other scientific publications,12,14,21-24 Vlaeyen and colleagues21 initially introduced their cognitive behavioral model of FA in 1995. Over the last 20 years, this original model has been expanded and renamed the FA model of chronic pain.4,22,23 This basic model proposes that, if one interprets the experience of pain (which is associated with or
without an actual injury) as significantly threatening and begins to catastrophize about it, then pain-related fear evolves. Negative catastrophic cognitions lead to avoidance of activities and hypervigilance in monitoring bodily and pain sensations, followed by withdrawal from recreation and family activities, which then can lead to depression, physical disuse, deconditioning, and disability. The formation of these self-imposed barriers to physical activity, in particular, leads to the formation of a negative-feedback loop, which further compounds the cyclical nature of physical decline.18,20 For patients who interpret the pain as nonthreatening, and who do not catastrophize, pain-related FA does not develop, and normalization of daily activities and rapid recovery are likely to occur. The Vlaeyen FA model has gained interest from both researchers and clinicians,13 and is now the generally
accepted FA model in the scientific pain literature.
PAIN-RELATED FA AND DISABILITY Of significant importance to the aforementioned FA model is the relationships between pain-related FA and disability. Turk and Monarch19 reviewed a wide range of research indicating that fear of movement and reinjury may be a better predictor of physical functional limitations than actual biomedical or underlying pathophysiological variables. There is also strong evidence that pain-related fear is more associated with perceived disability and reduced behavioral performance than with pain itself.5 For example, Vlaeyen and colleagues21 have reported that fear of movement/reinjury was a better predictor of chronic back pain patients’ self-reported disability than were factors such as the physiological sensory perception of pain, as well as any underlying biomedical findings. Davis and coworkers6 also found that FA beliefs were related to a longer duration of low back pain–related disability. A large number of other past and more recent studies have reported similar results.11 Gatchel7 has also emphasized the importance of this FA construct when treating patients with pain. Finally, a meta-analysis by Zale and colleagues28
Department of Psychology, College of Science, The University of Texas at Arlington, Arlington, TX. 2Productive Rehabilitation Institute of Dallas for Ergonomics, Dallas, TX. 3West Coast Spine Restoration Center, Riverside, CA. 4Department of Kinesiology, College of Nursing and Health Innovation, The University of Texas at Arlington, Arlington, TX. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Robert Gatchel, Department of Psychology, 201 Life Science Building., University of Texas at Arlington, 501 South Nedderman Drive, Arlington, TX 76019. E-mail: [email protected] t Copyright ©2016 Journal of Orthopaedic & Sports Physical Therapy® 1
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reported a positive relationship between pain-related fear and disability ranging in magnitude from moderate to large.
Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at Flinders Uni Sa 24092 on February 2, 2016. For personal use only. No other uses without permission. Copyright © 2016 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
THE MEASUREMENT OF FA BELIEFS With the great interest in the clinical importance of the relationship between pain-related FA and disability, it is not surprising that there have been efforts devoted to measuring this FA construct. A review article by Lundberg et al13 identified 5 questionnaires that were specifically designed to measure the construct of pain-related fear: the Fear-Avoidance of Pain Scale, the Fear of Pain Questionnaire, The Tampa Scale of Kinesiophobia (TSK), the Pain Anxiety Symptoms Scale (PASS), and the Fear-Avoidance Beliefs Questionnaire (FABQ). It should be noted that the Pain Catastrophizing Scale and several other less well-known FA-related measures are also available. Of the measures reviewed by Lundberg et al,13 the TSK, PASS, and FABQ are the most well known and well studied. They all measure components of the current Vlaeyen FA model, but each measure was developed before the model was widely known or accepted, so they were not specifically based on it. The TSK is perhaps the most studied FA-related measure. Kinesiophobia refers to fear of movement and activity resulting from a feeling of vulnerability to reinjury. The developers of the TSK, in Tampa, FL, first presented the TSK in an unpublished poster presentation at a professional conference. Interestingly, after translating the TSK from English into Dutch, Vlaeyen et al21 were the first to publish the TSK in a scientific article. This was the same article in which their initial cognitive behavioral model of FA was introduced. When describing their FA model in this 1995 paper, Vlaeyen and colleagues21 referred to “fear of movement/reinjury.” So, it appears that their original model was, in large part, based on the concept of kinesiophobia. Waddell and coworkers24 developed the FABQ in order to better evaluate and treat patients with low back pain.
The original version of the FABQ consisted of 16 items that were further divided into 2 main subscales, a 5-item subscale that assessed FA beliefs about physical activities (eg, “I should not do physical activities which [might] make my pain worse”) and an 11-item subscale that assessed FA beliefs about work (eg, “I cannot do my normal work with my present pain”). Patients were requested to rate each of these 16 items on a 7-point Likert scale, with a score ranging from 0 (“do not agree at all”) to 7 (“completely agree”). Because most of the items on the FABQ are specific to work, it appears to be limited to individuals who are currently working or who have recently been off work due to pain. The PASS was designed to measure pain-related anxiety. Although several versions of the scale have been reported, the most common has 20 items, each rated on a 5-point scale ranging from 0 (never) to 5 (always), with higher scores indicating higher levels of pain-related anxiety. The following pain-related anxiety severity levels have been recommended for clinical interpretation: mild, 0 to 34; moderate, 35 to 67; and severe, 68 to 100.3 Overall, in evaluating these different measures, Lundberg and colleagues12 concluded that the construct validity and responsiveness of these different measures were basically not supported and/ or were untested in terms of psychometric properties. One reason for these poor findings was that, for most of the questionnaires/measures, there was no appropriate conceptual model used to help develop them. They concluded that “more theoretical-driven research is needed to support the construct and thus the measurement of pain-fear.” In addition, Lundberg and coworkers13 point out that none of these measures provide cutoff scores (except the PASS) to help in clinical decision making, and that evidence of treatment responsiveness is lacking. Pincus and colleagues16 have also criticized both the TSK and FABQ for inadequate item specificity. Furthermore,
both Pincus et al16 and Rainville et al17 have noted that pain-related avoidance can stem from fear of increased pain, fear of injury or reinjury, or simply the pain experienced when performing the activity (without fear); yet, none of these wellknown FA-related measures attempt to assess these 3 domains. Finally, Neblett and colleagues15 have noted that some items on the PASS, FABQ, and Pain Ca tastrophizing Scale associate avoidance behaviors with pain, but no items on any of these 3 measures associate avoidance specifically with fear. The TSK does associate avoidance behaviors with fear of injury, but no items relate avoidance to fear of pain.
THE FEAR-AVOIDANCE COMPONENTS SCALE Crombez and colleagues4 recognized the need for a better and more comprehensive set of test items that would more effectively address the critical issues not considered in the earlier-developed questionnaires reviewed above. Such test items had to comprehensively assess all the cognitive, emotional, and behavioral components of the newer cognitive behavioral model. Unfortunately, the incorporation of these important components into a single measurement instrument has been absent from the scientific literature. In order to address this absence, Neblett and coworkers15 developed a new instrument, the Fear-Avoidance Components Scale (FACS). The FACS has been empirically documented to be a psychometrically sound and reliable measure, with high internal consistency (Cronbach α = .92). In addition, clinically relevant severity cutoff levels were created that will be useful to many clinicians and health care professionals who embrace the importance of the FA belief construct for better assessing and treating patients with pain and disability. As reviewed by Neblett et al15 and Gatchel and Neblett,9 the FACS consists of 20 separate items that are scored from 0 (“completely disagree”) to 5 (“completely agree”), resulting in a total possi-
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[ ble score of 100. Some of the FACS items include the following: “I try to avoid activities and movements that make my pain worse”; “My painful medical condition puts me at risk for future injuries (or reinjuries) for the rest of my life”; “I worry about my painful medical condition”; “Due to my painful medical condition, I have avoided strenuous activities (like doing heavy yard work or moving heavy furniture).” As importantly, the following FACS severity levels have been recommended for clinical interpretation: subclinical (0-20), mild (21-40), moderate (41-60), severe (61-80), and extreme (81-100). However, it is anticipated that these cutoff points will be very useful to clinicians assessing and treating patients with chronic pain conditions. In summary, the FACS was developed to incorporate important components of previous FA-related scales, within a framework of the most current FA model of Vlaeyen and coworkers.4,23 It is a comprehensive instrument, designed to assess patients with painful medical conditions. The full FACS can be found in the APPENDIX.
TREATMENT OF FA BELIEFS Although components of FA have been studied for many years, FA-specific treatments have received less clinical attention but are now beginning to be addressed.27 For example, Vlaeyen and colleagues23 developed a treatment model similar to that of cognitive behavioral treatment for phobias. First, they educate patients about the FA model and identify how the patients’ beliefs, feelings, and behaviors contribute to a cycle of FA and decreased physical and mental functioning. Next, they develop a hierarchy of feared behaviors and proceed to move up the hierarchy with in vivo exposure. In this way, clinicians introduce reality testing of the patient’s fears. So, if the patient is afraid that lifting a suitcase into the trunk of a car will cause reinjury of the low back, then, with clinician encouragement and supervision, patients are asked to lift a suitcase into the trunk several times, so that they can see for themselves that rein-
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jury will not automatically occur (as long as they take care to not lift an item that weighs too much). Such treatment development will be important for future pain-management efforts. For example, a recent review article determined that, in patients with low back pain of less than 6 months in duration, high FA beliefs were associated with more pain and disability, as well as poorer posttreatment work outcomes.26 Decreased FA beliefs during treatment were also associated with decreased pain and disability. The same review article found equivocal results for patients with chronic low back pain. Some studies have found associations among FA beliefs, pain, disability, and work outcomes, and some studies have not. A related review article determined that higher pain-related catastrophizing (a vital component of the FA model) was generally associated with more pain, disability, and delayed recovery.25 Of course, for chronic pain, this treatment component will need to be a part of other cognitive behavioral techniques and integrated into a more comprehensive interdisciplinary painmanagement intervention. Such comprehensive intervention programs have been found to be cost-effective and therapeutically effective in numerous studies.8,10
SUMMARY AND CONCLUSION As reviewed by Gatchel and colleagues,11 FA beliefs are significantly associated with the experience of pain, especially when the pain becomes chronic in nature. Indeed, it is not at all uncommon for patients with pain symptoms to experience emotional distress, such as fear or anxiety. There is no doubt that the anticipated threat of intense pain can “capture one’s attention” and that this attention can be difficult to disengage from. This will often result in the constant vigilance and monitoring of pain sensations, as well as the associated false belief that such pain sensations may be actual signs of reinjury or the progression of a serious disease. This, in turn, can cause even low-intensity sensations of pain to become unbear-
able for the person.7 These FA-related beliefs and anxieties may, in turn, lead individuals to avoid activities (eg, working or specific activities of daily living) that they perceive as potentially increasing or exacerbating the pain or increasing one’s chances of reinjury. Just the anticipation of increased pain or reinjury can further stimulate avoidance behaviors. Thus, a vicious cycle may develop, in which such fears contribute to the avoidance of many activities, leading to inactivity and, ultimately, to greater disability.2 Gatchel and colleagues11 have found strong evidence that such FA beliefs are closely related to increased pain and physical disability, as well as long-term sick leave. As summarized by Turk and Monarch,19 “Fear of pain, driven by the anticipation of pain and not by the sensory experience of pain, is a strong negative reinforcement for the persistence of avoidance behavior and the functional disability.” With this knowledge in mind, anyone who assesses and treats pain-related disability should also be prepared to assess and treat painrelated FA. t
REFERENCES 1. A smundson GJ, Norton PJ, Norton GR. Beyond pain: the role of fear and avoidance in chronicity. Clin Psychol Rev. 1999;19:97-119. 2. Boersma K, Linton SJ. Psychological processes underlying the development of a chronic pain problem: a prospective study of the relationship between profiles of psychological variables in the fear-avoidance model and disability. Clin J Pain. 2006;22:160-166. 3. Brede E, Mayer TG, Neblett R, Williams M, Gatchel RJ. The Pain Anxiety Symptoms Scale fails to discriminate pain or anxiety in a chronic disabling occupational musculoskeletal disorder population. Pain Pract. 2011;11:430-438. http:// dx.doi.org/10.1111/j.1533-2500.2011.00448.x 4. Crombez G, Eccleston C, Van Damme S, Vlaeyen JW, Karoly P. Fear-avoidance model of chronic pain: the next generation. Clin J Pain. 2012;28:475-483. http://dx.doi.org/10.1097/ AJP.0b013e3182385392 5. Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of painrelated fear in chronic back pain disability. Pain. 1999;80:329-339. http://dx.doi.org/10.1016/ S0304-3959(98)00229-2
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6. D avis DS, Mancinelli CA, Petronis JJ, Bensenhaver C, McClintic T, Nelson G. Variables associated with level of disability in working individuals with nonacute low back pain: a cross-sectional investigation. J Orthop Sports Phys Ther. 2013;43:97104. http://dx.doi.org/10.2519/jospt.2013.4382 7. Gatchel RJ. Clinical Essentials of Pain Management. Washington, DC: American Psychological Association; 2005. 8. Gatchel RJ, McGeary DD, McGeary CA, Lippe B. Interdisciplinary chronic pain management: past, present, and future. Am Psychol. 2014;69:119-130. http://dx.doi.org/10.1037/ a0035514 9. Gatchel RJ, Neblett R. Pain catastrophizing: what clinicians need to know. Pract Pain Manag. 2015;15:70-75. 10. Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. J Pain. 2006;7:779-793. http://dx.doi.org/10.1016/j. jpain.2006.08.005 11. Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133:581-624. http://dx.doi. org/10.1037/0033-2909.133.4.581 12. Lethem J, Slade PD, Troup JD, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception—I. Behav Res Ther. 1983;21:401-408. http://dx.doi. org/10.1016/0005-7967(83)90009-8 13. Lundberg M, Grimby-Ekman A, Verbunt J, Simmonds MJ. Pain-related fear: a critical review of the related measures. Pain Res Treat. 2011;2011:494196. http://dx.doi. org/10.1155/2011/494196 14. McCracken LM, Zayfert C, Gross RT. The
15.
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Pain Anxiety Symptoms Scale: development and validation of a scale to measure fear of pain. Pain. 1992;50:67-73. http://dx.doi. org/10.1016/0304-3959(92)90113-P Neblett R, Mayer TG, Hartzell MM, Williams MJ, Gatchel RJ. The Fear-Avoidance Components Scale (FACS): development and psychometric evaluation of a new measure of pain-related fear avoidance. Pain Pract. In press. http://dx.doi. org/10.1111/papr.12333 Pincus T, Smeets RJ, Simmonds MJ, Sullivan MJ. The fear avoidance model disentangled: improving the clinical utility of the fear avoidance model. Clin J Pain. 2010;26:739-746. http:// dx.doi.org/10.1097/AJP.0b013e3181f15d45 Rainville J, Smeets RJ, Bendix T, Tveito TH, Poiraudeau S, Indahl AJ. Fear-avoidance beliefs and pain avoidance in low back pain—translating research into clinical practice. Spine J. 2011;11:895-903. http://dx.doi.org/10.1016/j. spinee.2011.08.006 Tinetti ME, Doucette J, Claus E, Marottoli R. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc. 1995;43:1214-1221. Turk DC, Monarch ES. Biopsychosocial perspective on chronic pain. In: Turk DC, Gatchel RJ, eds. Psychological Approaches to Pain Management: A Practitioner’s Handbook. 2nd ed. New York, NY: The Guilford Press; 2002:3-29. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling and restriction of mobility in elderly fallers. Age Ageing. 1997;26:189-193. Vlaeyen JW, Kole-Snijders AM, Boeren RG, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62:363-372. http://dx.doi. org/10.1016/0304-3959(94)00279-N
22. V laeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317-332. http:// dx.doi.org/10.1016/S0304-3959(99)00242-0 23. Vlaeyen JW, Linton SJ. Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain. 2012;153:1144-1147. http://dx.doi.org/10.1016/j. pain.2011.12.009 24. Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993;52:157-168. http://dx.doi. org/10.1016/0304-3959(93)90127-B 25. Wertli MM, Burgstaller JM, Weiser S, Steurer J, Kofmehl R, Held U. Influence of catastrophizing on treatment outcome in patients with nonspecific low back pain: a systematic review. Spine (Phila Pa 1976). 2014;39:263-273. http://dx.doi. org/10.1097/BRS.0000000000000110 26. Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. Spine J. 2014;14:816-836.e4. http://dx.doi.org/10.1016/j.spinee.2013.09.036 27. Zale EL, Ditre JW. Pain-related fear, disability, and the fear-avoidance model of chronic pain. Curr Opin Psychol. 2015;5:24-30. http://dx.doi. org/10.1016/j.copsyc.2015.03.014 28. Zale EL, Lange KL, Fields SA, Ditre JW. The relation between pain-related fear and disability: a meta-analysis. J Pain. 2013;14:1019-1030. http:// dx.doi.org/10.1016/j.jpain.2013.05.005
@
MORE INFORMATION WWW.JOSPT.ORG
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APPENDIX
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FEAR-AVOIDANCE COMPONENTS SCALE Name: ID #: Date: / / Instructions: People respond to pain in different ways. We want to find out how you think and feel about your painful medical condition and how it has affected your activity level. Please think about how you have been over the past week, and circle one number between “0” and “5” from the scale below to answer each question. 5 = Completely agree 4 = Mostly agree 3 = Slightly agree
2 = Slightly disagree 1 = Mostly disagree 0 = Completely disagree
Over the past week, how much do you agree with these statements about your painful medical condition? Completely agree
Mostly agree
Slightly agree
Slightly disagree
Mostly disagree
Completely disagree
1. I try to avoid activities and movements that make my pain worse
5
4
3
2
1
0
2. I worry about my painful medical condition
5
4
3
2
1
0
3. I believe that my pain will keep getting worse until I won’t be able to function at all
5
4
3
2
1
0
4. I am overwhelmed by fear when I think about my painful medical condition
5
4
3
2
1
0
5. I don’t attempt certain activities because I am fearful that I will injure (or re-injure) myself
5
4
3
2
1
0
6. When my pain is really bad, I also have other symptoms such as nausea, difficulty breathing, heart pounding, trembling, and/or dizziness
5
4
3
2
1
0
7. It is unfair that I have to live with my painful medical condition
5
4
3
2
1
0
8. My painful medical condition puts me at risk for future injuries (or re-injuries) for the rest of my life
5
4
3
2
1
0
9. Because of my painful medical condition, my life will never be the same
5
4
3
2
1
0
10. I have no control over my pain
5
4
3
2
1
0
11. I don’t attempt certain activities and movements because I am fearful that my pain will increase
5
4
3
2
1
0
12. It is someone else’s fault that I have this painful medical condition
5
4
3
2
1
0
13. The pain from my medical condition is a warning signal that something is dangerously wrong with me
5
4
3
2
1
0
14. No one understands how severe my painful medical condition is
5
4
3
2
1
0
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APPENDIX
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Start each of the following items with this statement: Over the past week, due to my painful medical condition I have avoided the following… Completely agree
Mostly agree
Slightly agree
Slightly disagree
Mostly disagree
Completely disagree
15. Strenuous activities (like doing heavy yard work or moving heavy furniture)
5
4
3
2
1
0
16. Moderate activities (like cooking dinner or cleaning the house)
5
4
3
2
1
0
17. Light activities (like going to the movies or going out to lunch)
5
4
3
2
1
0
18. My full duties and chores at home and/or at work
5
4
3
2
1
0
19. Recreation and/or exercise (things that I do for fun and good health)
5
4
3
2
1
0
20. Activities where I have to use my painful body part(s)
5
4
3
2
1
0
Total Score: Version 8, Rev. 1/30/2014 Reprinted with permission from Neblett et al.14 ©John Wiley and Sons.
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ROBERT J. GATCHEL, PhD, ABPP1 • RANDY NEBLETT, MA, LPC, BCB2 NANCY KISHINO, OTR/L, CVE3 • CHRISTOPHER T. RAY, PhD, ATC, CSCS4
Fear-Avoidance Beliefs and Chronic Pain J Orthop Sports Phys Ther 2016;46(2):38-43. doi:10.2519/jospt.2016.0601
P
eople are motivated to avoid activities in which they have experienced acute episodes of pain in order to reduce the likelihood of re-experiencing pain or causing further physical damage. This is an adaptive behavioral strategy for dealing with situations involving acute pain, but it can become maladaptive when dealing with chronic pain.11,19,23 The relationship between painrelated fear avoidance (FA) and chronic pain has been studied for over 3 decades, especially in patients with musculoskeletal pain and disability.13 The relationship between fear and pain was first introduced by Lethem and colleagues in 1983.12 Their FA model of exaggerated pain perception proposed that, following an injury, patients would either confront pain (stay active, show a desire to return to work, etc) or avoid pain (resulting in FA, exaggerated pain perception, and eventual physical deconditioning and disability). This model further proposed that fear of pain and avoidance behaviors could become desynchronous from the actual sensory component of pain. Borrowing from Lethem et al12 and incorporating concepts from a number of other scientific publications,12,14,21-24 Vlaeyen and colleagues21 initially introduced their cognitive behavioral model of FA in 1995. Over the last 20 years, this original model has been expanded and renamed the FA model of chronic pain.4,22,23 This basic model proposes that, if one interprets the experience of pain (which is associated with or
without an actual injury) as significantly threatening and begins to catastrophize about it, then pain-related fear evolves. Negative catastrophic cognitions lead to avoidance of activities and hypervigilance in monitoring bodily and pain sensations, followed by withdrawal from recreation and family activities, which then can lead to depression, physical disuse, deconditioning, and disability. The formation of these self-imposed barriers to physical activity, in particular, leads to the formation of a negative-feedback loop, which further compounds the cyclical nature of physical decline.18,20 For patients who interpret the pain as nonthreatening, and who do not catastrophize, pain-related FA does not develop, and normalization of daily activities and rapid recovery are likely to occur. The Vlaeyen FA model has gained interest from both researchers and clinicians,13 and is now the generally
accepted FA model in the scientific pain literature.
PAIN-RELATED FA AND DISABILITY Of significant importance to the aforementioned FA model is the relationships between pain-related FA and disability. Turk and Monarch19 reviewed a wide range of research indicating that fear of movement and reinjury may be a better predictor of physical functional limitations than actual biomedical or underlying pathophysiological variables. There is also strong evidence that pain-related fear is more associated with perceived disability and reduced behavioral performance than with pain itself.5 For example, Vlaeyen and colleagues21 have reported that fear of movement/reinjury was a better predictor of chronic back pain patients’ self-reported disability than were factors such as the physiological sensory perception of pain, as well as any underlying biomedical findings. Davis and coworkers6 also found that FA beliefs were related to a longer duration of low back pain–related disability. A large number of other past and more recent studies have reported similar results.11 Gatchel7 has also emphasized the importance of this FA construct when treating patients with pain. Finally, a meta-analysis by Zale and colleagues28
Department of Psychology, College of Science, The University of Texas at Arlington, Arlington, TX. 2Productive Rehabilitation Institute of Dallas for Ergonomics, Dallas, TX. 3West Coast Spine Restoration Center, Riverside, CA. 4Department of Kinesiology, College of Nursing and Health Innovation, The University of Texas at Arlington, Arlington, TX. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Robert Gatchel, Department of Psychology, 201 Life Science Building., University of Texas at Arlington, 501 South Nedderman Drive, Arlington, TX 76019. E-mail: [email protected] t Copyright ©2016 Journal of Orthopaedic & Sports Physical Therapy® 1
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reported a positive relationship between pain-related fear and disability ranging in magnitude from moderate to large.
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THE MEASUREMENT OF FA BELIEFS With the great interest in the clinical importance of the relationship between pain-related FA and disability, it is not surprising that there have been efforts devoted to measuring this FA construct. A review article by Lundberg et al13 identified 5 questionnaires that were specifically designed to measure the construct of pain-related fear: the Fear-Avoidance of Pain Scale, the Fear of Pain Questionnaire, The Tampa Scale of Kinesiophobia (TSK), the Pain Anxiety Symptoms Scale (PASS), and the Fear-Avoidance Beliefs Questionnaire (FABQ). It should be noted that the Pain Catastrophizing Scale and several other less well-known FA-related measures are also available. Of the measures reviewed by Lundberg et al,13 the TSK, PASS, and FABQ are the most well known and well studied. They all measure components of the current Vlaeyen FA model, but each measure was developed before the model was widely known or accepted, so they were not specifically based on it. The TSK is perhaps the most studied FA-related measure. Kinesiophobia refers to fear of movement and activity resulting from a feeling of vulnerability to reinjury. The developers of the TSK, in Tampa, FL, first presented the TSK in an unpublished poster presentation at a professional conference. Interestingly, after translating the TSK from English into Dutch, Vlaeyen et al21 were the first to publish the TSK in a scientific article. This was the same article in which their initial cognitive behavioral model of FA was introduced. When describing their FA model in this 1995 paper, Vlaeyen and colleagues21 referred to “fear of movement/reinjury.” So, it appears that their original model was, in large part, based on the concept of kinesiophobia. Waddell and coworkers24 developed the FABQ in order to better evaluate and treat patients with low back pain.
The original version of the FABQ consisted of 16 items that were further divided into 2 main subscales, a 5-item subscale that assessed FA beliefs about physical activities (eg, “I should not do physical activities which [might] make my pain worse”) and an 11-item subscale that assessed FA beliefs about work (eg, “I cannot do my normal work with my present pain”). Patients were requested to rate each of these 16 items on a 7-point Likert scale, with a score ranging from 0 (“do not agree at all”) to 7 (“completely agree”). Because most of the items on the FABQ are specific to work, it appears to be limited to individuals who are currently working or who have recently been off work due to pain. The PASS was designed to measure pain-related anxiety. Although several versions of the scale have been reported, the most common has 20 items, each rated on a 5-point scale ranging from 0 (never) to 5 (always), with higher scores indicating higher levels of pain-related anxiety. The following pain-related anxiety severity levels have been recommended for clinical interpretation: mild, 0 to 34; moderate, 35 to 67; and severe, 68 to 100.3 Overall, in evaluating these different measures, Lundberg and colleagues12 concluded that the construct validity and responsiveness of these different measures were basically not supported and/ or were untested in terms of psychometric properties. One reason for these poor findings was that, for most of the questionnaires/measures, there was no appropriate conceptual model used to help develop them. They concluded that “more theoretical-driven research is needed to support the construct and thus the measurement of pain-fear.” In addition, Lundberg and coworkers13 point out that none of these measures provide cutoff scores (except the PASS) to help in clinical decision making, and that evidence of treatment responsiveness is lacking. Pincus and colleagues16 have also criticized both the TSK and FABQ for inadequate item specificity. Furthermore,
both Pincus et al16 and Rainville et al17 have noted that pain-related avoidance can stem from fear of increased pain, fear of injury or reinjury, or simply the pain experienced when performing the activity (without fear); yet, none of these wellknown FA-related measures attempt to assess these 3 domains. Finally, Neblett and colleagues15 have noted that some items on the PASS, FABQ, and Pain Ca tastrophizing Scale associate avoidance behaviors with pain, but no items on any of these 3 measures associate avoidance specifically with fear. The TSK does associate avoidance behaviors with fear of injury, but no items relate avoidance to fear of pain.
THE FEAR-AVOIDANCE COMPONENTS SCALE Crombez and colleagues4 recognized the need for a better and more comprehensive set of test items that would more effectively address the critical issues not considered in the earlier-developed questionnaires reviewed above. Such test items had to comprehensively assess all the cognitive, emotional, and behavioral components of the newer cognitive behavioral model. Unfortunately, the incorporation of these important components into a single measurement instrument has been absent from the scientific literature. In order to address this absence, Neblett and coworkers15 developed a new instrument, the Fear-Avoidance Components Scale (FACS). The FACS has been empirically documented to be a psychometrically sound and reliable measure, with high internal consistency (Cronbach α = .92). In addition, clinically relevant severity cutoff levels were created that will be useful to many clinicians and health care professionals who embrace the importance of the FA belief construct for better assessing and treating patients with pain and disability. As reviewed by Neblett et al15 and Gatchel and Neblett,9 the FACS consists of 20 separate items that are scored from 0 (“completely disagree”) to 5 (“completely agree”), resulting in a total possi-
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[ ble score of 100. Some of the FACS items include the following: “I try to avoid activities and movements that make my pain worse”; “My painful medical condition puts me at risk for future injuries (or reinjuries) for the rest of my life”; “I worry about my painful medical condition”; “Due to my painful medical condition, I have avoided strenuous activities (like doing heavy yard work or moving heavy furniture).” As importantly, the following FACS severity levels have been recommended for clinical interpretation: subclinical (0-20), mild (21-40), moderate (41-60), severe (61-80), and extreme (81-100). However, it is anticipated that these cutoff points will be very useful to clinicians assessing and treating patients with chronic pain conditions. In summary, the FACS was developed to incorporate important components of previous FA-related scales, within a framework of the most current FA model of Vlaeyen and coworkers.4,23 It is a comprehensive instrument, designed to assess patients with painful medical conditions. The full FACS can be found in the APPENDIX.
TREATMENT OF FA BELIEFS Although components of FA have been studied for many years, FA-specific treatments have received less clinical attention but are now beginning to be addressed.27 For example, Vlaeyen and colleagues23 developed a treatment model similar to that of cognitive behavioral treatment for phobias. First, they educate patients about the FA model and identify how the patients’ beliefs, feelings, and behaviors contribute to a cycle of FA and decreased physical and mental functioning. Next, they develop a hierarchy of feared behaviors and proceed to move up the hierarchy with in vivo exposure. In this way, clinicians introduce reality testing of the patient’s fears. So, if the patient is afraid that lifting a suitcase into the trunk of a car will cause reinjury of the low back, then, with clinician encouragement and supervision, patients are asked to lift a suitcase into the trunk several times, so that they can see for themselves that rein-
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jury will not automatically occur (as long as they take care to not lift an item that weighs too much). Such treatment development will be important for future pain-management efforts. For example, a recent review article determined that, in patients with low back pain of less than 6 months in duration, high FA beliefs were associated with more pain and disability, as well as poorer posttreatment work outcomes.26 Decreased FA beliefs during treatment were also associated with decreased pain and disability. The same review article found equivocal results for patients with chronic low back pain. Some studies have found associations among FA beliefs, pain, disability, and work outcomes, and some studies have not. A related review article determined that higher pain-related catastrophizing (a vital component of the FA model) was generally associated with more pain, disability, and delayed recovery.25 Of course, for chronic pain, this treatment component will need to be a part of other cognitive behavioral techniques and integrated into a more comprehensive interdisciplinary painmanagement intervention. Such comprehensive intervention programs have been found to be cost-effective and therapeutically effective in numerous studies.8,10
SUMMARY AND CONCLUSION As reviewed by Gatchel and colleagues,11 FA beliefs are significantly associated with the experience of pain, especially when the pain becomes chronic in nature. Indeed, it is not at all uncommon for patients with pain symptoms to experience emotional distress, such as fear or anxiety. There is no doubt that the anticipated threat of intense pain can “capture one’s attention” and that this attention can be difficult to disengage from. This will often result in the constant vigilance and monitoring of pain sensations, as well as the associated false belief that such pain sensations may be actual signs of reinjury or the progression of a serious disease. This, in turn, can cause even low-intensity sensations of pain to become unbear-
able for the person.7 These FA-related beliefs and anxieties may, in turn, lead individuals to avoid activities (eg, working or specific activities of daily living) that they perceive as potentially increasing or exacerbating the pain or increasing one’s chances of reinjury. Just the anticipation of increased pain or reinjury can further stimulate avoidance behaviors. Thus, a vicious cycle may develop, in which such fears contribute to the avoidance of many activities, leading to inactivity and, ultimately, to greater disability.2 Gatchel and colleagues11 have found strong evidence that such FA beliefs are closely related to increased pain and physical disability, as well as long-term sick leave. As summarized by Turk and Monarch,19 “Fear of pain, driven by the anticipation of pain and not by the sensory experience of pain, is a strong negative reinforcement for the persistence of avoidance behavior and the functional disability.” With this knowledge in mind, anyone who assesses and treats pain-related disability should also be prepared to assess and treat painrelated FA. t
REFERENCES 1. A smundson GJ, Norton PJ, Norton GR. Beyond pain: the role of fear and avoidance in chronicity. Clin Psychol Rev. 1999;19:97-119. 2. Boersma K, Linton SJ. Psychological processes underlying the development of a chronic pain problem: a prospective study of the relationship between profiles of psychological variables in the fear-avoidance model and disability. Clin J Pain. 2006;22:160-166. 3. Brede E, Mayer TG, Neblett R, Williams M, Gatchel RJ. The Pain Anxiety Symptoms Scale fails to discriminate pain or anxiety in a chronic disabling occupational musculoskeletal disorder population. Pain Pract. 2011;11:430-438. http:// dx.doi.org/10.1111/j.1533-2500.2011.00448.x 4. Crombez G, Eccleston C, Van Damme S, Vlaeyen JW, Karoly P. Fear-avoidance model of chronic pain: the next generation. Clin J Pain. 2012;28:475-483. http://dx.doi.org/10.1097/ AJP.0b013e3182385392 5. Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of painrelated fear in chronic back pain disability. Pain. 1999;80:329-339. http://dx.doi.org/10.1016/ S0304-3959(98)00229-2
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6. D avis DS, Mancinelli CA, Petronis JJ, Bensenhaver C, McClintic T, Nelson G. Variables associated with level of disability in working individuals with nonacute low back pain: a cross-sectional investigation. J Orthop Sports Phys Ther. 2013;43:97104. http://dx.doi.org/10.2519/jospt.2013.4382 7. Gatchel RJ. Clinical Essentials of Pain Management. Washington, DC: American Psychological Association; 2005. 8. Gatchel RJ, McGeary DD, McGeary CA, Lippe B. Interdisciplinary chronic pain management: past, present, and future. Am Psychol. 2014;69:119-130. http://dx.doi.org/10.1037/ a0035514 9. Gatchel RJ, Neblett R. Pain catastrophizing: what clinicians need to know. Pract Pain Manag. 2015;15:70-75. 10. Gatchel RJ, Okifuji A. Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain. J Pain. 2006;7:779-793. http://dx.doi.org/10.1016/j. jpain.2006.08.005 11. Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133:581-624. http://dx.doi. org/10.1037/0033-2909.133.4.581 12. Lethem J, Slade PD, Troup JD, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception—I. Behav Res Ther. 1983;21:401-408. http://dx.doi. org/10.1016/0005-7967(83)90009-8 13. Lundberg M, Grimby-Ekman A, Verbunt J, Simmonds MJ. Pain-related fear: a critical review of the related measures. Pain Res Treat. 2011;2011:494196. http://dx.doi. org/10.1155/2011/494196 14. McCracken LM, Zayfert C, Gross RT. The
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Pain Anxiety Symptoms Scale: development and validation of a scale to measure fear of pain. Pain. 1992;50:67-73. http://dx.doi. org/10.1016/0304-3959(92)90113-P Neblett R, Mayer TG, Hartzell MM, Williams MJ, Gatchel RJ. The Fear-Avoidance Components Scale (FACS): development and psychometric evaluation of a new measure of pain-related fear avoidance. Pain Pract. In press. http://dx.doi. org/10.1111/papr.12333 Pincus T, Smeets RJ, Simmonds MJ, Sullivan MJ. The fear avoidance model disentangled: improving the clinical utility of the fear avoidance model. Clin J Pain. 2010;26:739-746. http:// dx.doi.org/10.1097/AJP.0b013e3181f15d45 Rainville J, Smeets RJ, Bendix T, Tveito TH, Poiraudeau S, Indahl AJ. Fear-avoidance beliefs and pain avoidance in low back pain—translating research into clinical practice. Spine J. 2011;11:895-903. http://dx.doi.org/10.1016/j. spinee.2011.08.006 Tinetti ME, Doucette J, Claus E, Marottoli R. Risk factors for serious injury during falls by older persons in the community. J Am Geriatr Soc. 1995;43:1214-1221. Turk DC, Monarch ES. Biopsychosocial perspective on chronic pain. In: Turk DC, Gatchel RJ, eds. Psychological Approaches to Pain Management: A Practitioner’s Handbook. 2nd ed. New York, NY: The Guilford Press; 2002:3-29. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling and restriction of mobility in elderly fallers. Age Ageing. 1997;26:189-193. Vlaeyen JW, Kole-Snijders AM, Boeren RG, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62:363-372. http://dx.doi. org/10.1016/0304-3959(94)00279-N
22. V laeyen JW, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85:317-332. http:// dx.doi.org/10.1016/S0304-3959(99)00242-0 23. Vlaeyen JW, Linton SJ. Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain. 2012;153:1144-1147. http://dx.doi.org/10.1016/j. pain.2011.12.009 24. Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993;52:157-168. http://dx.doi. org/10.1016/0304-3959(93)90127-B 25. Wertli MM, Burgstaller JM, Weiser S, Steurer J, Kofmehl R, Held U. Influence of catastrophizing on treatment outcome in patients with nonspecific low back pain: a systematic review. Spine (Phila Pa 1976). 2014;39:263-273. http://dx.doi. org/10.1097/BRS.0000000000000110 26. Wertli MM, Rasmussen-Barr E, Weiser S, Bachmann LM, Brunner F. The role of fear avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: a systematic review. Spine J. 2014;14:816-836.e4. http://dx.doi.org/10.1016/j.spinee.2013.09.036 27. Zale EL, Ditre JW. Pain-related fear, disability, and the fear-avoidance model of chronic pain. Curr Opin Psychol. 2015;5:24-30. http://dx.doi. org/10.1016/j.copsyc.2015.03.014 28. Zale EL, Lange KL, Fields SA, Ditre JW. The relation between pain-related fear and disability: a meta-analysis. J Pain. 2013;14:1019-1030. http:// dx.doi.org/10.1016/j.jpain.2013.05.005
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APPENDIX
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FEAR-AVOIDANCE COMPONENTS SCALE Name: ID #: Date: / / Instructions: People respond to pain in different ways. We want to find out how you think and feel about your painful medical condition and how it has affected your activity level. Please think about how you have been over the past week, and circle one number between “0” and “5” from the scale below to answer each question. 5 = Completely agree 4 = Mostly agree 3 = Slightly agree
2 = Slightly disagree 1 = Mostly disagree 0 = Completely disagree
Over the past week, how much do you agree with these statements about your painful medical condition? Completely agree
Mostly agree
Slightly agree
Slightly disagree
Mostly disagree
Completely disagree
1. I try to avoid activities and movements that make my pain worse
5
4
3
2
1
0
2. I worry about my painful medical condition
5
4
3
2
1
0
3. I believe that my pain will keep getting worse until I won’t be able to function at all
5
4
3
2
1
0
4. I am overwhelmed by fear when I think about my painful medical condition
5
4
3
2
1
0
5. I don’t attempt certain activities because I am fearful that I will injure (or re-injure) myself
5
4
3
2
1
0
6. When my pain is really bad, I also have other symptoms such as nausea, difficulty breathing, heart pounding, trembling, and/or dizziness
5
4
3
2
1
0
7. It is unfair that I have to live with my painful medical condition
5
4
3
2
1
0
8. My painful medical condition puts me at risk for future injuries (or re-injuries) for the rest of my life
5
4
3
2
1
0
9. Because of my painful medical condition, my life will never be the same
5
4
3
2
1
0
10. I have no control over my pain
5
4
3
2
1
0
11. I don’t attempt certain activities and movements because I am fearful that my pain will increase
5
4
3
2
1
0
12. It is someone else’s fault that I have this painful medical condition
5
4
3
2
1
0
13. The pain from my medical condition is a warning signal that something is dangerously wrong with me
5
4
3
2
1
0
14. No one understands how severe my painful medical condition is
5
4
3
2
1
0
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APPENDIX
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Start each of the following items with this statement: Over the past week, due to my painful medical condition I have avoided the following… Completely agree
Mostly agree
Slightly agree
Slightly disagree
Mostly disagree
Completely disagree
15. Strenuous activities (like doing heavy yard work or moving heavy furniture)
5
4
3
2
1
0
16. Moderate activities (like cooking dinner or cleaning the house)
5
4
3
2
1
0
17. Light activities (like going to the movies or going out to lunch)
5
4
3
2
1
0
18. My full duties and chores at home and/or at work
5
4
3
2
1
0
19. Recreation and/or exercise (things that I do for fun and good health)
5
4
3
2
1
0
20. Activities where I have to use my painful body part(s)
5
4
3
2
1
0
Total Score: Version 8, Rev. 1/30/2014 Reprinted with permission from Neblett et al.14 ©John Wiley and Sons.
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