Fear Avoidance

The concept of fear-avoidance beliefs grew from a model of exaggerated pain perception, suggesting that individuals fall along a continuum ranging from a tendency to confront a painful experience by remaining active to a tendency to avoid movement and activity because of pain-related fear. Avoidance of activity is thought to contribute to disuse, deconditioning, and pain-related disability.

Research demonstrates that fear-avoidance beliefs predict the future onset of new low back pain. That is, pain-free individuals who believe that physical or work activities should be avoided when in pain or that such activity is dangerous have a greater likelihood of developing low back pain in the future. Similar findings demonstrate a relationship between pain catastrophizing, pain-related fear, and fear-avoidance beliefs with the onset of new low back pain. Noting the presence of fear-avoidance beliefs in pain-free individuals, Leeuw and colleagues suggest that these beliefs may be a vulnerability factor for the inception of new low back pain, perhaps by influencing how ambiguous physical sensations are interpreted.

Workplace Factors

Dissatisfaction with work is predictive of new onset of low back pain. Studies longitudinally following subjects who were pain-free or had only minor prior episodes of low back pain found that dissatisfaction with work status, perceived inadequacy of income, and performance of unskilled or manual tasks were associated with future medical consultations for low back pain. Perceived lack of social support from a supervisor or coworkers was associated with the future reporting of low back pain in several studies. Workers who report having limited control over their work, an excessive workload, or low job satisfaction have increased risk of future back pain.

Psychological Distress

Elevated levels of psychological distress in pain-free individuals have been associated with future episodes of low back pain. In a longitudinal study that followed occupationally active adults over a 12-year period, researchers found that level of emotional distress at baseline predicted long-term low back disability.

Abuse History

It is extremely difficult to conduct a prospective study to determine the effect of abuse on the subsequent onset of low back pain, although at least one study has done just that. Linton assessed the history of prior physical or sexual abuse in a group of women who reported some or no spinal pain at the time of initial assessment. One year later, for those without pain at baseline, prior physical but not sexual abuse was associated with new occurrences of spinal pain. Physical and sexual abuse were associated with increased episodes of functional problems at one-year follow-upfor this group. For the group reporting pain at baseline, neither physical nor sexual abuse predicted pain or disability at follow-up. Because a history of abuse may be associated with family dysfunction or psychopathology, it is difficult to make a clear connection between abuse versus other psychosocial factors and subsequent pain problems.

Within a Fear-Avoidance Model

One way to review the interaction of cognitive, emotional, behavioral, and social/environmental factors is within one of the more dominant models of chronic pain development, the fear-avoidance model. In this model, the experience of pain is met with cognitive appraisal of the meaning and significance of pain. If pain is appraised as a benign experience, as from muscle soreness or minor strain, the individual is less likely to experience fear and more likely to maintain or quickly resume normal activities, which in turn can lead to rapid recovery. Conversely, if pain is appraised as a sign of severe injury or dangerous medical condition, that is, if the individual engages in catastrophic pain cognitions, the individual is likely to become fearful. Pain-related fear leads to avoidance of movement or activities that the individual believes will cause greater pain, further injury, or repeat injury. Avoidance of movement and activity can lead to a downward spiral of progressive deconditioning and increased pain and the development of disability, helplessness, and depression.

Pain catastrophizing, an exaggerated and dysfunctional negative appraisal of pain as a threat, is the cognitive precursor to pain-related fear. Cognitive appraisal includes other cognitions, such as expectations of recovery, belief in the need for passive treatments, and cognitive coping style. High fear-avoidance beliefs and negative recovery expectations contribute to the transition to chronic pain and disability. Appraisal of pain as a threat also is likely to trigger increased attention, anticipation, or hypervigilance to pain, which can result in increased brain activity in pain-sensitive brain regions and increased intensity of pain. Catastrophic pain cognitions and higher levels of fear-avoidance beliefs are associated with exaggerated predictions of pain severity, less tolerance for physical activities, and higher levels of self-reported disability.

The pain-related fear resulting from catastrophic pain cognitions and fear-avoidance beliefs can produce many avoidance behaviors. These might include lack of movement or activity and abnormal postures or movement patterns designed to avoid pain, such as limping, guarding, and bracing. These avoidance behaviors can be operantly reinforced by their effect on reducing or controlling pain. Avoidance of movement can minimize pain and reduce pain-related fear, each a positive consequence reinforcing avoidance behavior. Over time, avoidance behaviors can become highly resistant to extinction. Indeed, if avoidance is the predominant response, there is limited opportunity to learn that movement or activity is possible without negative consequences. Avoidance behaviors can be reinforced via other consequences, including attention and support from family, avoidance of responsibilities or an unpleasant work environment, or financial compensation.

Continued pain-avoidance behaviors ultimately result in loss of strength, endurance, and flexibility and, in very chronic situations, can result in severe health consequences, such as obesity, cardiovascular disease, and Type II diabetes. It also probably leads to increasing pain severity and loss of ability to engage in the functional and rewarding activities of life. Often, when chronic pain sufferers realize that they are not recovering as initially expected and, in fact, are declining further into pain and disability, their depression and other forms of emotional distress become severe.

Each person may develop fear-avoidance beliefs in different ways. Starting in childhood, one suffers minor and sometimes more serious injuries and typically experiences pain many times during one’s life. Each pain experience is a learning opportunity that may serve to shape one’s belief systems. How parents and others respond to a child in pain may teach that child that pain is a normal part of life and nothing to be feared, or conversely, that pain is a signal that something could be seriously wrong, thus requiring concern and attention. Someone who participates in competitive sports may learn that minor pains should be ignored and should not affect athletic performance. Those performing heavy labor jobs may similarly learn that pain is a normal and routine part of life and can usually be ignored. Each person also has vicarious learning experiences from observing role models respond to painful experiences. These can be members of the family or community, professional athletes, or characters from television and films. Fear-avoidance beliefs develop in many ways and exist even before the onset of pain.

Fear-avoidance beliefs might also be influenced by health-care providers who have developed their own systems of fear-avoidance beliefs. Providers with high levels of fear-avoidance beliefs are more likely to advise patients to avoid painful movements, more likely to recommend sick leave as a valuable treatment for pain, and less likely to encourage patients to maintain as many normal physical activities as are tolerable. These recommendations are contrary to most current back-pain guidelines that recommend advising patients to remain active. Providers who caution patients to avoid movement and activity or who keep them out of work until pain improves are probably reinforcing greater pain-related fear and worry in their patients.

Reinforcement of Pain Behavior

Another variable contributing to the transition to chronic pain involves the degree to which pain behavior is reinforced. According to operant theory, behavior that produces positive consequences for the individual will probably increase in frequency, whereas behavior that is punished or ignored is likely to decrease in frequency or extinguish. Dysfunctional pain cognitions, such as belief in the need for passive treatments, the thought that movement is dangerous, or the expectation of long-term disability, can also be influenced by environmental contingencies. Spouses, family members, friends, and others can inadvertently reinforce dysfunctional pain behaviors or cognitions by attention, sympathy, assistance with tasks, or other solicitous responses. Whether a consequence is positive or not depends on the perspective of each individual. For some individuals, for example those that highly value their independence, offers of assistance might be perceived as negative consequences. To the extent that there are positive consequences for an individual following pain behaviors, those behaviors are likely to continue happening.

Financial reinforcement may be a factor when pain has resulted from an industrial injury and there may be disability payments or a pending future financial settlement. Most people who are disabled by back pain experience associated financial loss and, therefore, have an incentive for recovery. However, if disability income while off work closely approximates what would be earned if on the job, pain behavior might be reinforced by the combination of work avoidance and financial compensation, especially with a dissatisfied employee. Patients with limited formal education who were earning a high income performing skilled heavy labor may receive more disability income than they can ever hope to receive if they return to work at a lighter-duty job. This can certainly maintain pain behaviors.

Sometimes it is hard to understand the ways in which pain behavior is being reinforced. It can be reinforced by positive consequences or by avoidance or escape from negative situations. It might involve a spouse who was previously distant but is now more attentive and affectionate. It might be a mother who enjoys being a homemaker, and who can spend time with her children because of her low back pain disability, but who otherwise could not afford to be unemployed. It might be a worker bored with the job and dissatisfied with the income who is hoping to be retrained for an easier and better-paying occupation. It might be a middle-aged worker in a highly stressful job requiring long work hours who also has taken on the care of an elderly parent and whose pain behavior is reinforced via escape from an overly stressful lifestyle. It could also be an unhappy husband who now has an acceptable reason to turn back unwanted sexual advances from his spouse. A psychological evaluation for chronic low back pain seeks to identify via behavioral analysis how pain behavior is being operantly maintained.

As mentioned earlier, pain behaviors, such as limping, guarding, bracing, reclining, and not exercising, or other behaviors designed to avoid pain can be directly reinforced by the reduction of pain and the pain-related fear associated with certain movements or activities. These avoidance behaviors may be appropriate following an acute injury, thus allowing healing to occur. Continuing to avoid normal movement patterns after complete healing is one of the primary causes for continued pain and disability. It is common for secondary pain problems to result from sustained abnormal movements or inactivity. The longer pain behaviors continue, the more likely that they will become influenced by external contingencies, such as attention, sympathy, or assistance from others.

Medical providers can become the source of reinforcement for pain behaviors and thus contribute to the development of chronic pain. Attention and concern from caring medical professionals can be a powerful source of reinforcement for many individuals. If the provider encourages excessive avoidance of physical activity, extended time off work, ongoing use of opioid medication, and suspension of normal household responsibilities, the provider may be reinforcing pain behavior and disability. Patients’ beliefs and pain cognitions are also susceptible to operant reinforcement. Ordering unnecessary tests or referring the patient for another opinion may reinforce the belief that something serious might have been missed. Being uncertain while reassuring a patient (“I don’t think it is necessary to get a surgical opinion; it is very unlikely that you have anything wrong that would require surgery”) can reinforce beliefs that it is still possible that something serious has been missed. Telling patients to “take it easy” or “listen to your body” might reinforce their belief that it is dangerous to be physically active or that pain is a sign of injury.

Depression

Depression is common in chronic low back pain. The prevalence tends to be 2 to 3 times greater than in the general population. In patients with substantial disability associated with pain, such as those seen in pain clinics, the prevalence is far greater, affecting most patients. Depression increases with greater pain severity, when there is more than one pain problem, when pain is unexplained by medical findings, and when pain becomes chronic. When depression coexists with a chronic medical condition, there is greater functional impairment, more symptoms without identified pathology, greater health-care use, and higher costs.

For coexisting pain and depression, most evidence suggests that depression develops after the onset of pain, often after it becomes apparent that pain is not resolving. Acute pain typically does not produce depression, because it is likely that the acutely injured person expects recovery to occur and pain to resolve. When pain becomes chronic and is accompanied by disability, financial loss, and negative social consequences, the person in pain responds with a range of cognitions, some of which can trigger depression. Those with more positive cognitive coping skills may not develop depression. Banks and Kerns presented a diathesis stress model of pain and depression wherein each individual may have preexisting psychological characteristics, including negative schemas, attributions leading to learned helplessness, and skills deficits that can predispose to the development of depression. When an individual with more negative psychological characteristics experiences chronic pain, impairment and disability associated with pain, and perceived invalidating responses from others, they are at greater risk of depression. Conversely, persons with more positive cognitive schemas, better coping skills, and a validating and supportive social environment may weather chronic pain without severe emotional distress.

Although for most co-occurring pain and depression, depression is a response to pain and associated life changes, it can also exist before pain. Although the findings are not consistent across studies, there are data that suggest that depression may predispose someone to the onset of low back pain. An individual who is already clinically depressed at the time of injury or who has a history of recurrent depression may have more negative cognitive schemas, a more passive coping style, and fewer psychological and social resources to cope effectively with an injury.

The diagnosis of depression is often missed, especially in an individual presenting with complaints of pain. Physicians have limited time to address medical and psychological issues, and the psychological ones, if addressed, usually are addressed briefly. Patients with strong somatization tendencies are often unaware of their own depression, and others do not report depressive symptoms because of the perceived social stigma of a mental health problem or their fear that pain complaints would be discounted as arising from psychological problems.

Even when depression is correctly diagnosed, treatment is usually inadequate. The first-line approach to treatment of major depression in recent years has been antidepressant medication, choosing antidepressant medication or psychotherapy, specifically cognitive behavioral or interpersonal therapy, or medication and psychotherapy. The choice of treatment options has been left to patient and clinician preference or cost considerations. However, the efficacy of antidepressants has been brought into question by extensive literature reviews. These reviews included published and unpublished studies and suggested some selective reporting of research results, with those demonstrating efficacy of antidepressants much more likely to be published than those showing negative or questionable results. These studies raise serious questions about the value of antidepressants for most depressed individuals. Recent reviews have found little antidepressant benefit for mild and moderate depression but suggested more serious depression was somewhat responsive to antidepressant medications. These results suggest that treating depressed individuals with antidepressants alone may be a poor alternative to other treatments with known efficacy, such as cognitive behavioral therapy. Despite the limited scientific support for the use of antidepressants in most patients, providers and patients believe strongly in their efficacy, perhaps because of a combination of significant placebo response, extensive marketing, and biased reporting in the literature.

The real danger in only prescribing antidepressants is the risk that patients may not accept responsibility for resolving their depression. For patients with chronic low back pain, there may be many negative life changes contributing to depression, including occupational disability, financial stress, sleep disruption, negative health consequences, relationship distress, sexual dysfunction, family role changes, and limitations in social, recreational, and household activities. It is no wonder that depression is so common. To expect medication alone to improve mood in the face of all these changes is not realistic. Conversely, cognitive behavioral therapy can help develop cognitive coping strategies and behavioral action plans to resolve many of these problems.

Within a Fear-Avoidance Model

One way to review the interaction of cognitive, emotional, behavioral, and social/environmental factors is within one of the more dominant models of chronic pain development, the fear-avoidance model. In this model, the experience of pain is met with cognitive appraisal of the meaning and significance of pain. If pain is appraised as a benign experience, as from muscle soreness or minor strain, the individual is less likely to experience fear and more likely to maintain or quickly resume normal activities, which in turn can lead to rapid recovery. Conversely, if pain is appraised as a sign of severe injury or dangerous medical condition, that is, if the individual engages in catastrophic pain cognitions, the individual is likely to become fearful. Pain-related fear leads to avoidance of movement or activities that the individual believes will cause greater pain, further injury, or repeat injury. Avoidance of movement and activity can lead to a downward spiral of progressive deconditioning and increased pain and the development of disability, helplessness, and depression.

Pain catastrophizing, an exaggerated and dysfunctional negative appraisal of pain as a threat, is the cognitive precursor to pain-related fear. Cognitive appraisal includes other cognitions, such as expectations of recovery, belief in the need for passive treatments, and cognitive coping style. High fear-avoidance beliefs and negative recovery expectations contribute to the transition to chronic pain and disability. Appraisal of pain as a threat also is likely to trigger increased attention, anticipation, or hypervigilance to pain, which can result in increased brain activity in pain-sensitive brain regions and increased intensity of pain. Catastrophic pain cognitions and higher levels of fear-avoidance beliefs are associated with exaggerated predictions of pain severity, less tolerance for physical activities, and higher levels of self-reported disability.

The pain-related fear resulting from catastrophic pain cognitions and fear-avoidance beliefs can produce many avoidance behaviors. These might include lack of movement or activity and abnormal postures or movement patterns designed to avoid pain, such as limping, guarding, and bracing. These avoidance behaviors can be operantly reinforced by their effect on reducing or controlling pain. Avoidance of movement can minimize pain and reduce pain-related fear, each a positive consequence reinforcing avoidance behavior. Over time, avoidance behaviors can become highly resistant to extinction. Indeed, if avoidance is the predominant response, there is limited opportunity to learn that movement or activity is possible without negative consequences. Avoidance behaviors can be reinforced via other consequences, including attention and support from family, avoidance of responsibilities or an unpleasant work environment, or financial compensation.

Continued pain-avoidance behaviors ultimately result in loss of strength, endurance, and flexibility and, in very chronic situations, can result in severe health consequences, such as obesity, cardiovascular disease, and Type II diabetes. It also probably leads to increasing pain severity and loss of ability to engage in the functional and rewarding activities of life. Often, when chronic pain sufferers realize that they are not recovering as initially expected and, in fact, are declining further into pain and disability, their depression and other forms of emotional distress become severe.

Each person may develop fear-avoidance beliefs in different ways. Starting in childhood, one suffers minor and sometimes more serious injuries and typically experiences pain many times during one’s life. Each pain experience is a learning opportunity that may serve to shape one’s belief systems. How parents and others respond to a child in pain may teach that child that pain is a normal part of life and nothing to be feared, or conversely, that pain is a signal that something could be seriously wrong, thus requiring concern and attention. Someone who participates in competitive sports may learn that minor pains should be ignored and should not affect athletic performance. Those performing heavy labor jobs may similarly learn that pain is a normal and routine part of life and can usually be ignored. Each person also has vicarious learning experiences from observing role models respond to painful experiences. These can be members of the family or community, professional athletes, or characters from television and films. Fear-avoidance beliefs develop in many ways and exist even before the onset of pain.

Fear-avoidance beliefs might also be influenced by health-care providers who have developed their own systems of fear-avoidance beliefs. Providers with high levels of fear-avoidance beliefs are more likely to advise patients to avoid painful movements, more likely to recommend sick leave as a valuable treatment for pain, and less likely to encourage patients to maintain as many normal physical activities as are tolerable. These recommendations are contrary to most current back-pain guidelines that recommend advising patients to remain active. Providers who caution patients to avoid movement and activity or who keep them out of work until pain improves are probably reinforcing greater pain-related fear and worry in their patients.

Reinforcement of Pain Behavior

Another variable contributing to the transition to chronic pain involves the degree to which pain behavior is reinforced. According to operant theory, behavior that produces positive consequences for the individual will probably increase in frequency, whereas behavior that is punished or ignored is likely to decrease in frequency or extinguish. Dysfunctional pain cognitions, such as belief in the need for passive treatments, the thought that movement is dangerous, or the expectation of long-term disability, can also be influenced by environmental contingencies. Spouses, family members, friends, and others can inadvertently reinforce dysfunctional pain behaviors or cognitions by attention, sympathy, assistance with tasks, or other solicitous responses. Whether a consequence is positive or not depends on the perspective of each individual. For some individuals, for example those that highly value their independence, offers of assistance might be perceived as negative consequences. To the extent that there are positive consequences for an individual following pain behaviors, those behaviors are likely to continue happening.

Financial reinforcement may be a factor when pain has resulted from an industrial injury and there may be disability payments or a pending future financial settlement. Most people who are disabled by back pain experience associated financial loss and, therefore, have an incentive for recovery. However, if disability income while off work closely approximates what would be earned if on the job, pain behavior might be reinforced by the combination of work avoidance and financial compensation, especially with a dissatisfied employee. Patients with limited formal education who were earning a high income performing skilled heavy labor may receive more disability income than they can ever hope to receive if they return to work at a lighter-duty job. This can certainly maintain pain behaviors.

Sometimes it is hard to understand the ways in which pain behavior is being reinforced. It can be reinforced by positive consequences or by avoidance or escape from negative situations. It might involve a spouse who was previously distant but is now more attentive and affectionate. It might be a mother who enjoys being a homemaker, and who can spend time with her children because of her low back pain disability, but who otherwise could not afford to be unemployed. It might be a worker bored with the job and dissatisfied with the income who is hoping to be retrained for an easier and better-paying occupation. It might be a middle-aged worker in a highly stressful job requiring long work hours who also has taken on the care of an elderly parent and whose pain behavior is reinforced via escape from an overly stressful lifestyle. It could also be an unhappy husband who now has an acceptable reason to turn back unwanted sexual advances from his spouse. A psychological evaluation for chronic low back pain seeks to identify via behavioral analysis how pain behavior is being operantly maintained.

As mentioned earlier, pain behaviors, such as limping, guarding, bracing, reclining, and not exercising, or other behaviors designed to avoid pain can be directly reinforced by the reduction of pain and the pain-related fear associated with certain movements or activities. These avoidance behaviors may be appropriate following an acute injury, thus allowing healing to occur. Continuing to avoid normal movement patterns after complete healing is one of the primary causes for continued pain and disability. It is common for secondary pain problems to result from sustained abnormal movements or inactivity. The longer pain behaviors continue, the more likely that they will become influenced by external contingencies, such as attention, sympathy, or assistance from others.

Medical providers can become the source of reinforcement for pain behaviors and thus contribute to the development of chronic pain. Attention and concern from caring medical professionals can be a powerful source of reinforcement for many individuals. If the provider encourages excessive avoidance of physical activity, extended time off work, ongoing use of opioid medication, and suspension of normal household responsibilities, the provider may be reinforcing pain behavior and disability. Patients’ beliefs and pain cognitions are also susceptible to operant reinforcement. Ordering unnecessary tests or referring the patient for another opinion may reinforce the belief that something serious might have been missed. Being uncertain while reassuring a patient (“I don’t think it is necessary to get a surgical opinion; it is very unlikely that you have anything wrong that would require surgery”) can reinforce beliefs that it is still possible that something serious has been missed. Telling patients to “take it easy” or “listen to your body” might reinforce their belief that it is dangerous to be physically active or that pain is a sign of injury.

Depression

Depression is common in chronic low back pain. The prevalence tends to be 2 to 3 times greater than in the general population. In patients with substantial disability associated with pain, such as those seen in pain clinics, the prevalence is far greater, affecting most patients. Depression increases with greater pain severity, when there is more than one pain problem, when pain is unexplained by medical findings, and when pain becomes chronic. When depression coexists with a chronic medical condition, there is greater functional impairment, more symptoms without identified pathology, greater health-care use, and higher costs.

For coexisting pain and depression, most evidence suggests that depression develops after the onset of pain, often after it becomes apparent that pain is not resolving. Acute pain typically does not produce depression, because it is likely that the acutely injured person expects recovery to occur and pain to resolve. When pain becomes chronic and is accompanied by disability, financial loss, and negative social consequences, the person in pain responds with a range of cognitions, some of which can trigger depression. Those with more positive cognitive coping skills may not develop depression. Banks and Kerns presented a diathesis stress model of pain and depression wherein each individual may have preexisting psychological characteristics, including negative schemas, attributions leading to learned helplessness, and skills deficits that can predispose to the development of depression. When an individual with more negative psychological characteristics experiences chronic pain, impairment and disability associated with pain, and perceived invalidating responses from others, they are at greater risk of depression. Conversely, persons with more positive cognitive schemas, better coping skills, and a validating and supportive social environment may weather chronic pain without severe emotional distress.

Although for most co-occurring pain and depression, depression is a response to pain and associated life changes, it can also exist before pain. Although the findings are not consistent across studies, there are data that suggest that depression may predispose someone to the onset of low back pain. An individual who is already clinically depressed at the time of injury or who has a history of recurrent depression may have more negative cognitive schemas, a more passive coping style, and fewer psychological and social resources to cope effectively with an injury.

The diagnosis of depression is often missed, especially in an individual presenting with complaints of pain. Physicians have limited time to address medical and psychological issues, and the psychological ones, if addressed, usually are addressed briefly. Patients with strong somatization tendencies are often unaware of their own depression, and others do not report depressive symptoms because of the perceived social stigma of a mental health problem or their fear that pain complaints would be discounted as arising from psychological problems.

Even when depression is correctly diagnosed, treatment is usually inadequate. The first-line approach to treatment of major depression in recent years has been antidepressant medication, choosing antidepressant medication or psychotherapy, specifically cognitive behavioral or interpersonal therapy, or medication and psychotherapy. The choice of treatment options has been left to patient and clinician preference or cost considerations. However, the efficacy of antidepressants has been brought into question by extensive literature reviews. These reviews included published and unpublished studies and suggested some selective reporting of research results, with those demonstrating efficacy of antidepressants much more likely to be published than those showing negative or questionable results. These studies raise serious questions about the value of antidepressants for most depressed individuals. Recent reviews have found little antidepressant benefit for mild and moderate depression but suggested more serious depression was somewhat responsive to antidepressant medications. These results suggest that treating depressed individuals with antidepressants alone may be a poor alternative to other treatments with known efficacy, such as cognitive behavioral therapy. Despite the limited scientific support for the use of antidepressants in most patients, providers and patients believe strongly in their efficacy, perhaps because of a combination of significant placebo response, extensive marketing, and biased reporting in the literature.

The real danger in only prescribing antidepressants is the risk that patients may not accept responsibility for resolving their depression. For patients with chronic low back pain, there may be many negative life changes contributing to depression, including occupational disability, financial stress, sleep disruption, negative health consequences, relationship distress, sexual dysfunction, family role changes, and limitations in social, recreational, and household activities. It is no wonder that depression is so common. To expect medication alone to improve mood in the face of all these changes is not realistic. Conversely, cognitive behavioral therapy can help develop cognitive coping strategies and behavioral action plans to resolve many of these problems.