“Essentially, all models are wrong, but some are useful.” (George E.P. Box) Models are tools to help us better understand. From better understanding, comes better action. The fear avoidance model of pain has been around for close to 40 years. It’s concise and simple schematic is attractive. But I have reservations. Enough that I hesitate to teach it and apply it. I want to note that as a physical therapist I approach this from a clinical rehabilitation perspective. Not everyone will agree with this opinion, but I am hardly the only one. While it is appealing and easy to grasp, I worry about the mis-interpretation and mis-application by clinicians..
Fear avoidance language is widely used by clinicians. I contend that the term “fear avoidance” is a negative linguistic descriptor that can bias clinicians and interrupt therapeutic alliance. When Kori et al introduced the concept of kinesiophobia in 1990 they defined it as follows: “an excessive, irrational, and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or reinjury.” This definition stems from actual phobias, like agoraphobia. I promise, no one wants to be thought of as irrational, especially as it relates to their suffering. I’ve seen this definition quoted often in studies. Why wouldn’t a clinician’s take away from this, be that the fear and worry is unfounded if it cannot be correlated with physical harm? I am not saying that fear of pain and suffering and worry don’t exist. I’m saying that they are important and valid. Fear is a normal outcome expectation of a system that anticipates that the action will lead to an increase in suffering. It is logical and rationale. When fear avoidance models are the feature of care for those experiencing persistent pain, it has the potential to cause harm if a clinician conflates these self preserving actions as an indication that the individual lacks mental toughness. I have heard practitioners identify fear avoidance as a lack of cognitive, behavioral, and psychological fortitude. Fear and avoidance of tasks is therefore unnecessary and deemed incorrect.
Feeling dismissed and gaslit is a common experience expressed by those with persistent pain. I think it is more important for clinicians to hold the view that fear is an expression of a lack of confidence in their perceived safety and ability to perform an action. We should not be passing judgement on its validity or rationality. Or interpret these actions as that the individual is “not trying and therefore doesn’t want to get better” if they don’t continue to subject themselves to a known symptom irritant. Or worse, accusing someone of faking if they are seen performing one task, but unable to perform another without consideration for context and a host of other factors that contribute to action. Confrontation in the model can be misused to push an individual to perform an action they are not prepared for, whether that is physically tolerant to, or perceptually prepared for. In doing so, therapeutic alliance and trust can be negatively impacted.
The flow of information is unidirectional, omits the person, context, environment, and hope. It excludes the influence of the mediating and moderating effect of self-efficacy on outcomes. It is logical to conclude from this model that reducing distressed thinking through education, can reduce fear. Perhaps reassuring them that “nothing is wrong”, may feel MORE distressing. Delivering education about pain or movement to change people’s beliefs, has not entirely held up in the evidence. In doing so we have conflated didactic learning with updating beliefs. That is not how beliefs are formed. We seek to maintain our beliefs and bias incoming information that reinforces our beliefs because we feel more in control of a world we understand. Simply receiving “facts” is not how beliefs change. I wrote about it here. I worry that a focus on the fear avoidance model can distract clinicians from more reliable and positive treatments. A change of thought on the part of the clinician to: “this person is suffering and would benefit from developing strategies to feel better” paves a way forward. Self-efficacy has moderating effects on the relationships proposed in the model. I’ve discussed this previously here. In Van Damme and Kindermans’ review, they posit that persistence and avoidance behaviors are active, purposeful strategies to self-regulate that are the result of goals, not fear. Avoidance is not inherently bad, it is a strategy to self-regulate. We can acknowledge the validity of their strategy, and advise on developing new strategies too.
The messaging of this model is that fear and avoidance are harmful thoughts and behaviors, that will inevitably lead to disability. How is a clinician supposed to interpret this clinically? By labeling a maneuver, action, or inaction as based in fear implies it is the wrong approach. This itself breeds uncertainty and distress. If my patient identifies a narrow set of things that help them feel better, it is harmful for me to tell them that those are bad. Fear avoidance as a treatment target can promote education and exposure based interventions (doing the thing that hurts every time you do it.) It positions “avoidance” as the wrong behavior unless physical harm can be predicted. The model can lead to a circular argument. Avoidance behavior is wrong because it can lead to disability. Therefore, avoidant strategies should be avoided. Fear however, is normal, avoidance, is normal. It would be better to spend my time applauding their ability to find relief while exploring new ways for them to self-manage and expand movement variety toward their goals.
In the next installment of this blog series, I will review the model and relationships within the schematic and changes to the model.
Crombez G, Eccleston C, Van Damme S, Vlaeyen JWS, Karoly P. Fear- avoidance model of chronic pain: the next generation. Clin J Pain 2012; 28:475–83.
Holloway, I., Sofaer-Bennett, B., & Walker, J. (2007). The stigmatisation of people with chronic back pain. Disability and Rehabilitation, 29(18), 1456–1464.
MJ,SullivanMJL, HaythornthwaiteJA, EdwardsRR. Rethinking the fear avoidance model: toward a multidimensional framework of pain-related disability. PAIN 2013;154:2262–5.
Van Damme, S., & Kindermans, H. (2015). A Self-Regulation Perspective on Avoidance and Persistence Behavior in Chronic Pain. The Clinical Journal of Pain,31(2), 115-122.
Vlaeyen, J., Crombez, G. and Linton, S., 2016. The fear-avoidance model of pain. PAIN, 157(8), pp.1588-1589.
©2020 DevraJoy LLC. All rights reserved.