Rethinking relationships between fear, avoidance and pain-related disability
Working as a physical therapist, I have sometimes struggled to understand why some of my patients with seemingly similar musculoskeletal injuries recover and why others develop chronic pain and disability.
explore how psychosocial and physiological factors shape the rehabilitation process.
In a nutshell, the FAM [Fear Avoidance Model] suggests that individuals who don’t fear their pain will continue to engage in physical activities and therefore recover without difficulty.
This must not be pain that has concrete physical mechanisms (like defective connective tissue).
On one hand, we are told not to take pain medications so that we can feel when we’re hurting and avoid that activity. This implies pain should be listened to, but now we’re told that we should ignore pain and keep doing the activities that cause it.
On the other hand, people that catastrophically interpret their pain (think, magnified threat, persistent negative thoughts and feeling helpless) begin to fear, and then avoid, movements and activities associated with their pain.
The model suggests that over time these individuals avoid increasingly more activities, become physically deconditioned (a process known as Disuse Syndrome) and depressed, and that all of this nastiness helps perpetuate a downward spiral of increasing disability and pain.
There have only been a handful of studies that have systematically evaluated these cyclical relationships over time and, thus far, have largely failed to support them.
On the other hand, there has been preliminary support for alternate, cumulative, relationships among the psychological risk factors in the FAM (i.e. catastrophizing, fear, depression). This work suggests that people with a greater number of elevated risk factors (e.g. those with elevated catastrophizing and fear and depression) have a worse prognosis than those with fewer risk factors.
This work suggests that many individuals live with chronic pain without experiencing pronounced disability or psychological distress. Related research suggests that these individuals may have resilience factors (think, high optimism, deep sense of purpose) that act as a buffer to the potentially detrimental aspects of pain.
A third aspect of the FAM that we explore is Disuse Syndrome, the proposed mechanism through which fear-avoidance causes disability.
They demonize fearful avoidance of pain, yet this is the only biological purpose of pain – to make us stop doing what hurts. To blithely override that instinct is dangerous without being sure that the pain is not functional, i.e. caused and worsened by a physical process.
In so many pain syndromes, we aren’t sure what the causes are, yet this fear-avoidance model is being applied generally to the whole pain population.
the historic conceptualization of pain-related fear as phobia
for instance, the Tampa Scale of Kinesiophobia tends to focus on beliefs and behaviours while overlooking distress, a defining quality of phobia
we need to consider multiple pathways to disability, not only those associated with fear and avoidance
Our previous models have overwhelmingly focused on the psychological interpretation of, and behavioral response to, pain. While these processes are essential in explaining pain-related disability, so are biological, social, cultural, environmental and developmental factors. Developing a framework that integrates a more comprehensive range of these factors is consistent with both our current conceptualization of pain and with the World Health Organization’s classification of disability
I find it insulting that my worsening chronic pain is so casually being dismissed as being a result of fear, when EDS is clearly a physical impairment and medical problem (as well as Fibromyalgia).