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People Factors
Fear of pain is likely to slow recovery

At a glance:
Soreness can cause people to fear. In turn the fear can cause them to stop doing the things that cause the pain. Instead of getting better they get stiff and become unable to do the things they would normally. Fear avoidance then becomes the problem that the person is really suffering from.
People respond to pain in different ways. For example a farmer may have trouble with back pain, particularly when handling hay bales. He might see this as a normal part of life, and not really notice it unless it's particularly bad. A bad episode might be managed with some medication or an afternoon off.

Another person with a similar condition might be very anxious. When the pain doesn't improve they worry it may get worse and fear they won't be able to function normally or keep working. This might stop the person from engaging in their normal activities and eventually they stop working.

In most cases, people who have less anxiety about body pain and continue their normal activities manage better.

If you are fearful of the direction your condition is going in, get some good advice. This might mean finding a doctor you're comfortable with or preparing a list of questions you need answered. Having good information lets you relax and be confident in the way you're managing the condition. It makes a big difference.
People worry about back problems, what their pain means and the future.

Encourage people to get the information they need to be comfortable with the road ahead. This might make them less anxious about their problem, which can encourage them to become active and manage their recovery.
Fear of pain and its consequences lead people to seek investigation and treatment. Yet the treatment they get often does not improve outcomes, and can make them worse. It is important to understand the person's beliefs about their condition and ensure they understand what their pain means.

While rest is rarely recommended for back pain these days, people still believe that they need to avoid some activities so their body can heal. Often, these activities actually heal recovery. Inactivity makes people stiffer, less fit, and results in psychosocial
Refers to psychological and social factors. Examples of psychosocial factors that affect return to work area include: a person's beliefs about how they will cope with their condition, the attitude of the inured worker's family to their condition and return to work, the employer's return to work policy and the influence of the WorkCover system on a person.

A restriction of someone's activities should only be advised if the advice is evidence-based and appropriate explanations have been made.
People experiencing pain often worry about their situation. They can be uncertain about the future and fearful of their condition.

Encourage people to get good advice about their condition. This allows them to be confident in self management and their abilities, and makes a return to normal activities more likely.
Original Article, Authors & Publication Details:
Maaike Leeuw,1 Marielle E. J. B. Goossens,1 Steven J. Linton,2 Geert Crombez,3 Katja Boersma,2 and Johan W. S. Vlaeyen1,4 (2007)

The fear-avoidance model of musculoskeletal
Involving the muscles and the skeleton. This term includes the limbs, neck, shoulders and back. 'Musculoskeletal problem' refers to many different conditions that can affect the tendons, muscles and related structures.
 pain: current state of scientific evidence
. Journal of Behavioral Medicine;30(1):77-94.

1Department of Medical, Clinical, and Experimental Psychology, Maastricht University, Maastricht, The Netherlands.
2Department of Behavioral, Social, and Legal Sciences-Psychology, Orebro¨ University, Orebro, Sweden.
3Department of Experimental-Clinical and Health Psychology, Ghent University, Ghent, Belgium.
4Pain Management and Research Centre, University Hospital Maastricht, Maastricht, The Netherlands.

Background, Study Objectives, How It Was Done:
An episode of low back pain usually resolves itself, but for a minority of people it develops into a significant ongoing problem that causes reduced function, disability, or long term incapacitation. Often people in this group have much the same physical conditions as those who recover well. Without looking beyond physical factors alone, we can't explain the wide variation of outcomes that we see.

Fear is not always negative: it is an important and useful emotional reaction to a threat.

The fear avoidance model was developed about 20 years ago in an attempt to explain why a small minority of people with a condition develop long term problems while most recover. This paper reviews research on the model and seeks to update it. The model suggests that people react to pain depending on how they interpret it. Individuals can perceive pain in one of two ways:

a. Nonthreatening and understandable
When people experience pain this way, they are likely to keep up their normal activities. This promotes recovery.
b. Damaging or harmful
Perceiving pain in this way can make people more fearful of painful activities. This means an increase in avoidant behaviour, heightened awareness of pain, and an increased focus on avoiding pain. This can slow or prevent recovery.
Recovery outcomes can depend more on the persons concerns and beliefs about pain than the actual pain or condition itself.

Study Findings:
Research is summarised into two categories:

1. Contributing factors to fear and avoidance
2. Treatment approaches to fear and avoidance

Contributing factors

Pain severity

More intense initial pain contributes to ongoing fear and avoidance. People are fearful of returning to the initial severe pain and the associated restriction in what they can do.

Pain catastrophising,

The patient dwells on the worst possible negative consequences of the situation. This means pain is more likely to be interpreted as a threat, and leads some people to avoid their normal activities.
When the person experiencing the pain believes that it is causing damage or harm they rate it as more painful, and report worse consequences.

Attention to pain

Fear of pain increases a person's attention to pain. This can make it harder to manage complex tasks because a person's attention is diverted away from the task and towards their pain. Those more fearful of their back pain, for example, don't perform as well in tasks that require concentration and complex thought.
The anticipation of pain and concentration on the experience can prolong the problem and be a factor in long term disability.

Avoidance behaviour

“Avoidance behaviour' means postponing or preventing something that the person is afraid will turn out badly. While it is not possible to avoid chronic
continuing a long time or recurring frequently
 pain, people may avoid activities which they think might increase pain or cause re-injury.
Studies have shown that people with heightened fear of pain walk more slowly and exert themselves less, even in activities not normally expected to cause pain or re-injury.


Avoiding activity leads to reduced fitness and muscle strength, sometimes called ‘the disuse syndrome'.
Patients with chronic low back pain have diminished muscle strength, poorer trunk muscle coordination, and, according to some studies, lower physical fitness.


The following factors seem to make a person more vulnerable to heightened fear of pain and pain catastrophising:

1. The person's level of general anxiety
2. The person's degree of focus on injury and illness
3. The person's fear of health conditions, or neuroticism

Treatment approaches

Patients who are fearful of their condition may be more likely to keep searching for biomedical
Applying understanding from the biological and physiological sciences to clinical medicine.
 explanations, and have multiple investigations and treatment from which they don't gain much benefit. This can frustrate patient and treaters.

It has been suggested that pain related fear interferes with communication between the patient and their treating practitioners, and can be detrimental to these relationships.

Treating practitioners sometimes increase a patient's fear. Diagnoses such as "degenerative disc" or “ruptured disc" can cause fear. If treating practitioners
treating practitioner
A health professional that treats patients. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc.
 are highly fear avoidant they are likely to be very focused on medical causes, which may reinforce the patient's focus. Patients who are particularly worried or anxious are often sensitive to hesitations or inconsistencies from their treating practitioners, however small.

Effectiveness of cognitive
relating to the mental processes of perception, memory, judgment, and reasoning
 behaviour programs

Recent programs have included strategies for addressing pain related fear. These programs have produced positive results.

Educating patients about fear and avoidance and providing a graded exercise program reduced disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 more than standard care programs did. Public awareness campaigns have also had some impact, decreasing fear of back pain and increasing awareness of how important it is to remain active.

People who are more fearful of their pain and avoid their normal activities seem not to recovery as well as others. Pain is often misinterpreted, leading people to behave in ways that might not help.

Some activities that help people to recover cause pain, but this does not necessarily mean they cause harm. If patients identify all pain as harmful they might not behave in ways that help them to recover.

Factors that contribute to fear and avoidance include:

1. The severity of the initial pain
2. The individual's personality
3. The treating practitioners approach and attitude
4. Lack of knowledge/understanding of the condition

PubMed Abstract
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